Healthcare Provider Details

I. General information

NPI: 1336181197
Provider Name (Legal Business Name): PETER T JOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W NORTH AVE
MELROSE PARK IL
60160-1612
US

IV. Provider business mailing address

701 W NORTH AVE
MELROSE PARK IL
60160-1612
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-3200
  • Fax:
Mailing address:
  • Phone: 708-681-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number036103200
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: