Provider Demographics
NPI:1588959530
Name:ZAVISLAK, PETER THOMAS (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:THOMAS
Last Name:ZAVISLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W HARRISON ST
Mailing Address - Street 2:SUITE 466
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3800
Mailing Address - Country:US
Mailing Address - Phone:312-942-5000
Mailing Address - Fax:
Practice Address - Street 1:600 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3806
Practice Address - Country:US
Practice Address - Phone:312-942-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079931A207L00000X
IL036135255207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001566166OtherANTHEM PTAN
IN1102571187OtherANTHEM PTAN
IN300015863Medicaid