Provider Demographics
NPI:1255484028
Name:LEO G. PEPA, M.D.,LTD.
Entity Type:Organization
Organization Name:LEO G. PEPA, M.D.,LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:K
Authorized Official - Last Name:DREVS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-428-0400
Mailing Address - Street 1:2425 ROYAL BLVD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2507
Mailing Address - Country:US
Mailing Address - Phone:847-428-0400
Mailing Address - Fax:847-428-0534
Practice Address - Street 1:2425 RPYAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2507
Practice Address - Country:US
Practice Address - Phone:847-428-0400
Practice Address - Fax:847-428-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044641Medicaid
IL1669551685OtherNPI
IL=========OtherTAX ID
IL036044641Medicaid
IL244570Medicare ID - Type UnspecifiedMEDICARE