Basic Information
| Provider Information | |||||||||
| NPI: | 1336181197 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086813200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086813200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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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 | 207RA0000X | 036103200 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036103200 | 05 | IL | MEDICAID |