Provider Demographics
NPI:1518042449
Name:LISA J. PETERS, MD, S.C.
Entity Type:Organization
Organization Name:LISA J. PETERS, MD, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-386-2400
Mailing Address - Street 1:2717 N DAYTON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1409
Mailing Address - Country:US
Mailing Address - Phone:708-386-2400
Mailing Address - Fax:847-432-2174
Practice Address - Street 1:7339 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1543
Practice Address - Country:US
Practice Address - Phone:708-386-2400
Practice Address - Fax:708-366-8458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH69997Medicare UPIN
IL209552Medicare ID - Type Unspecified