Provider Demographics
NPI:1528022191
Name:KAKAVAS, PETER W (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:W
Last Name:KAKAVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:13011 S 104TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1508
Practice Address - Country:US
Practice Address - Phone:708-274-3278
Practice Address - Fax:708-274-3299
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083840207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621208OtherBLUECROSS BLUESHIELD
IL416810OtherMEDICARE GROUP
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL236551OtherMEDICARE GROUP
ILCG1672OtherRAILROAD MEDICARE GROUP PTAN NUMBER
ILCN2703OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL01621208OtherBLUE CROSS BLUE SHIELD GROUP NUMBER
IL060047092OtherRAILROAD MEDICARE WILL
IL1508810086OtherHEART CARE CENTERS OF ILLINOIS GROUP NPI
IL036083840Medicaid
IL060047092OtherRAILROAD MEDICARE COOK
IL060056850OtherRAILROAD MEDICARE KANKAKE
IL236550OtherMEDICARE GROUP
ILCG1672OtherRAILROAD MEDICARE GROUP PTAN NUMBER
G02277Medicare UPIN
ILL68229Medicare ID - Type Unspecified
IL236550OtherMEDICARE GROUP