Healthcare Provider Details

I. General information

NPI: 1487640660
Provider Name (Legal Business Name): WOLF D PEDDINGHAUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 KNOX AVE SUITE 102
SKOKIE IL
60076-1256
US

IV. Provider business mailing address

9701 KNOX AVE SUITE 102
SKOKIE IL
60076-1256
US

V. Phone/Fax

Practice location:
  • Phone: 847-677-1112
  • Fax: 847-674-3358
Mailing address:
  • Phone: 847-677-1112
  • Fax: 847-674-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36053477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: