Provider Demographics
NPI:1265414700
Name:BANDY, PEGGY L (MD)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:L
Last Name:BANDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N WESTERN AVE SUITE 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1774
Mailing Address - Country:US
Mailing Address - Phone:312-491-5086
Mailing Address - Fax:312-491-5485
Practice Address - Street 1:1431 N WESTERN AVE STE 401
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1774
Practice Address - Country:US
Practice Address - Phone:312-491-5086
Practice Address - Fax:312-491-5485
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100321Medicaid
IL036100321OtherIL STATE LICENSE
IL036100321Medicaid
ILG98029Medicare UPIN