Provider Demographics
NPI:1508962838
Name:DEMIKIS, PEGGY P (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:P
Last Name:DEMIKIS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-324-7911
Mailing Address - Fax:630-324-7942
Practice Address - Street 1:ONE INGALLS DR
Practice Address - Street 2:W536
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426
Practice Address - Country:US
Practice Address - Phone:708-915-6870
Practice Address - Fax:708-333-9105
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL67625Medicaid
ILL67625Medicaid
ILL95346Medicare PIN