Healthcare Provider Details

I. General information

NPI: 1205803483
Provider Name (Legal Business Name): PETER HERBERT NEALE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18127 WILLIAM ST
LANSING IL
60438-3921
US

IV. Provider business mailing address

27702 NETWORK PL
CHICAGO IL
60673-1277
US

V. Phone/Fax

Practice location:
  • Phone: 708-889-6621
  • Fax: 708-889-6675
Mailing address:
  • Phone: 708-862-7674
  • Fax: 708-862-1781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002162A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036073399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: