Healthcare Provider Details

I. General information

NPI: 1467288043
Provider Name (Legal Business Name): MADISON NICOLE PETERSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 N MICHIGAN AVE STE 720
CHICAGO IL
60611-6661
US

IV. Provider business mailing address

920 N YORK RD STE 100
HINSDALE IL
60521-3515
US

V. Phone/Fax

Practice location:
  • Phone: 312-319-1978
  • Fax: 312-262-7791
Mailing address:
  • Phone: 312-319-1978
  • Fax: 312-262-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: