Provider Demographics
NPI:1023005097
Name:PETERS, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:PETERS
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 1:3360 LACROSSE LN
Mailing Address - Street 2:SUITE 106
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8136
Mailing Address - Country:US
Mailing Address - Phone:630-696-4404
Mailing Address - Fax:630-696-4405
Practice Address - Street 1:3360 LACROSSE LN
Practice Address - Street 2:SUITE 106
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8136
Practice Address - Country:US
Practice Address - Phone:630-696-4404
Practice Address - Fax:630-696-4405
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078421Medicare ID - Type Unspecified
C41421Medicare UPIN
ILK39348Medicare PIN