Basic Information
| Provider Information | |||||||||
| NPI: | 1205803483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEALE | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | HERBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27702 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088627674 | ||||||||
| FaxNumber: | 7088621781 | ||||||||
| Practice Location | |||||||||
| Address1: | 18127 WILLIAM ST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604383921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088896621 | ||||||||
| FaxNumber: | 7088896675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02002162A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036073399 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 231199029 | 01 | IL | MEDICARE | OTHER | 080096730 | 01 | IL | RRM | OTHER | 036073399 | 05 | IL | MEDICAID |