Provider Demographics
NPI:1215021647
Name:C.G.PETERS LLC
Entity Type:Organization
Organization Name:C.G.PETERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-389-9226
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-0276
Mailing Address - Country:US
Mailing Address - Phone:708-389-9226
Mailing Address - Fax:708-389-2004
Practice Address - Street 1:13305 S RIDGELAND AVE
Practice Address - Street 2:UNIT B
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1808
Practice Address - Country:US
Practice Address - Phone:708-389-9226
Practice Address - Fax:708-389-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107020Medicaid
ILH65087Medicare UPIN
IL036107020Medicaid