Provider Demographics
NPI:1972986024
Name:PERETS, ITAY (SA)
Entity type:Individual
Prefix:
First Name:ITAY
Middle Name:
Last Name:PERETS
Suffix:
Gender:M
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-920-2350
Mailing Address - Fax:630-323-5625
Practice Address - Street 1:1010 EXECUTIVE DR
Practice Address - Street 2:SUITE 250
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-6135
Practice Address - Country:US
Practice Address - Phone:630-920-2350
Practice Address - Fax:630-323-5625
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000456246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare PIN