Healthcare Provider Details

I. General information

NPI: 1417584541
Provider Name (Legal Business Name): KYLE S PETERSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 S MARYLAND AVE
CHICAGO IL
60637-1426
US

IV. Provider business mailing address

1845 S MICHIGAN AVE UNIT 1510
CHICAGO IL
60616-2497
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-3222
  • Fax:
Mailing address:
  • Phone: 815-260-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License Number041411744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: