Healthcare Provider Details

I. General information

NPI: 1760419311
Provider Name (Legal Business Name): PETER T HEYDEMANN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST #710
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

5731 S KENWOOD AVE
CHICAGO IL
60637-1718
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-4036
  • Fax: 312-563-2507
Mailing address:
  • Phone: 312-942-4036
  • Fax: 312-563-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-051342
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number3651342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: