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General NPI Number Information
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NPI Number | 1639148372
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Entity Type | Individual
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Provider Name | PETER LOREN JAGGARD MD
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Gender | Male
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Dates
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Enumeration Date | 03/15/2006
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Last Update Date | 12/14/2015
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Provider Practice Location Address
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Address Line | 3200 GRANT ST
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City | EVANSTON
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State | IL
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Zip | 60201
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Country | US
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Telephone | 847-492-4828
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Fax | 847-492-4810
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Provider Business Mailing Address
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Address Line | 3200 GRANT ST
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City | EVANSTON
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State | IL
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Zip | 60201-1903
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Country | US
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Telephone | 847-492-4842
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Fax | 847-492-4829
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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 | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 036062564
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License Number State | IL
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