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General NPI Number Information
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NPI Number | 1174202543
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Entity Type | Individual
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Provider Name | ELIZABETH PETERSEN
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Gender | Female
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 1969 W OGDEN AVE
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City | CHICAGO
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State | IL
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Zip | 60612-3765
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Country | US
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Telephone | 312-864-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 1531 INSPIRATION DR APT 3017
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City | DALLAS
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State | TX
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Zip | 75207-3767
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Country | US
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Telephone | 720-985-7589
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208U00000X
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Taxonomy Name | Clinical Pharmacology Physician
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License Number | 051305104
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License Number State | IL
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