Healthcare Provider Details

I. General information

NPI: 1538268230
Provider Name (Legal Business Name): PETER JOSEPH PUTHENVEETIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GREENLEAF ST STE 1
PARK CITY IL
60085-5744
US

IV. Provider business mailing address

401 GREENLEAF ST STE 1
PARK CITY IL
60085-5744
US

V. Phone/Fax

Practice location:
  • Phone: 847-662-0978
  • Fax: 847-662-1395
Mailing address:
  • Phone: 847-662-0978
  • Fax: 847-662-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036108104
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: