Healthcare Provider Details

I. General information

NPI: 1184638496
Provider Name (Legal Business Name): PETER M. COLEGROVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
GALENA IL
61036-8118
US

IV. Provider business mailing address

2650 RIDGE AVE EVANSTON HOSPITAL
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-1340
  • Fax: 815-776-7274
Mailing address:
  • Phone: 847-570-1206
  • Fax: 847-570-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036112977
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: