Basic Information
| Provider Information | |||||||||
| NPI: | 1184943441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDILLO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Practice Location | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2010 | ||||||||
| LastUpdateDate: | 05/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 4301046721 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4301046721 | 01 | MI | STATE LICENSE | OTHER |