Provider Demographics
NPI:1942902135
Name:PETESCH, TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:PETESCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:KNOPF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3437 W BELLE PLAINE AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2282
Mailing Address - Country:US
Mailing Address - Phone:630-450-5925
Mailing Address - Fax:
Practice Address - Street 1:1555 BARRINGTON RD BLDG 1
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1099
Practice Address - Country:US
Practice Address - Phone:847-843-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.081721207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program