Healthcare Provider Details

I. General information

NPI: 1588744650
Provider Name (Legal Business Name): KEVIN LOUIS PETERMANN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 W 95TH ST STE 303
OAK LAWN IL
60453-2572
US

IV. Provider business mailing address

3820 NORTHDALE BLVD STE 201
TAMPA FL
33624-1893
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6117
  • Fax: 888-812-8191
Mailing address:
  • Phone: 813-961-1331
  • Fax: 888-850-8316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number036141794
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number232845
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME118086
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036141794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: