Healthcare Provider Details

I. General information

NPI: 1215498597
Provider Name (Legal Business Name): ALLYSON ELAYNE PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3800
  • Fax: 773-907-1005
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number83254-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01089804A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036159608
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: