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General NPI Number Information
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NPI Number | 1417584541
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Entity Type | Individual
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Provider Name | KYLE S PETERSON RN
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Gender | Male
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Dates
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Enumeration Date | 03/26/2020
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Last Update Date | 04/10/2020
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Provider Practice Location Address
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Address Line | 5700 S MARYLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60637-1426
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Country | US
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Telephone | 773-702-3222
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Fax |
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Provider Business Mailing Address
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Address Line | 1845 S MICHIGAN AVE UNIT 1510
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City | CHICAGO
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State | IL
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Zip | 60616-2497
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Country | US
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Telephone | 815-260-4322
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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 | 163WF0300X
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Taxonomy Name | Flight Registered Nurse
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License Number | 041411744
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License Number State | IL
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