Provider Demographics
NPI:1942280326
Name:ROUMELIOTIS, PETER CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CHARLES
Last Name:ROUMELIOTIS
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 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:1300 W. DRESDEN DRIVE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450
Practice Address - Country:US
Practice Address - Phone:815-942-5200
Practice Address - Fax:815-942-5330
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085485Medicaid
IL020475OtherHEALTH ALLIANCE
IL003204876OtherBLUE CROSS
F65363Medicare UPIN
IL020475OtherHEALTH ALLIANCE