Healthcare Provider Details

I. General information

NPI: 1467452755
Provider Name (Legal Business Name): PETER D CLADIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 FARGO BLVD
GENEVA IL
60134-3591
US

IV. Provider business mailing address

2425 FARGO BLVD
GENEVA IL
60134-3591
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-2200
  • Fax: 630-232-1940
Mailing address:
  • Phone: 630-232-2200
  • Fax: 630-232-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: