1508962838 NPI number — PEGGY P DEMIKIS PHYSICIAN ASSISTANT

Table of content: PEGGY P DEMIKIS PHYSICIAN ASSISTANT (NPI 1508962838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508962838 NPI number — PEGGY P DEMIKIS PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMIKIS
Provider First Name:
PEGGY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508962838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 WARRENVILLE RD
Provider Second Line Business Mailing Address:
SUITE 280
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-324-7911
Provider Business Mailing Address Fax Number:
630-324-7942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE INGALLS DR
Provider Second Line Business Practice Location Address:
W536
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-915-6870
Provider Business Practice Location Address Fax Number:
708-333-9105
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085000466 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: L67625 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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