Healthcare Provider Details

I. General information

NPI: 1578547428
Provider Name (Legal Business Name): PETE D STAVRIDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

V. Phone/Fax

Practice location:
  • Phone: 618-546-1294
  • Fax: 618-546-2673
Mailing address:
  • Phone: 618-546-1294
  • Fax: 618-546-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: