Provider Demographics
NPI:1275755738
Name:THE CENTER FOR FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:THE CENTER FOR FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-904-4351
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-078421OtherSTATE LICENSE
IL215287Medicare PIN
C41421Medicare UPIN