Healthcare Provider Details

I. General information

NPI: 1669546131
Provider Name (Legal Business Name): WALTER A PEDEMONTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 NORTH AVE
OAK PARK IL
60302-1020
US

IV. Provider business mailing address

414 CLINTON PL
RIVER FOREST IL
60305-2255
US

V. Phone/Fax

Practice location:
  • Phone: 708-445-0480
  • Fax: 708-445-0495
Mailing address:
  • Phone: 708-366-4926
  • Fax: 708-445-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: