Provider Demographics
NPI:1114198678
Name:REVENAUGH, PETER CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:REVENAUGH
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 1:1611 W HARRISON ST STE 550
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-942-6100
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST STE 550
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-136085207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology