Provider Demographics
NPI:1760452775
Name:PETERSON, BRADFORD G (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:G
Last Name:PETERSON
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:PO BOX 239D
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8018
Mailing Address - Country:US
Mailing Address - Phone:847-759-1560
Mailing Address - Fax:847-803-1006
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:PALOS COMMUNITY HOSPITAL
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-5700
Practice Address - Fax:708-923-8848
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093195207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093195Medicaid
IL050046667OtherRR MEDICARE