Provider Demographics
NPI:1205947983
Name:PENEGOR, MARITTA A (NP-BC)
Entity type:Individual
Prefix:
First Name:MARITTA
Middle Name:A
Last Name:PENEGOR
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 PARK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1186
Mailing Address - Country:US
Mailing Address - Phone:708-748-9800
Mailing Address - Fax:708-748-9807
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:SUITE 401
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-865-0893
Practice Address - Fax:219-865-3599
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000040A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00150268OtherRAILROAD MEDICARE
P00150268OtherRAILROAD MEDICARE
P60833Medicare UPIN
IN406310QMedicare PIN