Provider Demographics
NPI:1427525666
Name:PENDERGAST, MICHAEL JR (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PENDERGAST
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CURTISS ST APT B1
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4518
Mailing Address - Country:US
Mailing Address - Phone:309-331-3448
Mailing Address - Fax:
Practice Address - Street 1:9701 W HIGGINS RD STE 270
Practice Address - Street 2:
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4703
Practice Address - Country:US
Practice Address - Phone:847-692-3715
Practice Address - Fax:815-986-4218
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085006827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant