Healthcare Provider Details

I. General information

NPI: 1750509097
Provider Name (Legal Business Name): PEGGY THORNTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 115TH ST
CHICAGO IL
60628-5015
US

IV. Provider business mailing address

1661 W 104TH ST
CHICAGO IL
60643-2822
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-2800
  • Fax:
Mailing address:
  • Phone: 773-445-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: