Basic Information
| Provider Information | |||||||||
| NPI: | 1760431373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HURTEAU | ||||||||
| FirstName: | PEGGIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21333 HAGGERTY RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486620250 | ||||||||
| FaxNumber: | 2486629844 | ||||||||
| Practice Location | |||||||||
| Address1: | 393 E EDWARDSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WOOD RIVER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620951646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182594111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00322265 | 01 | IL | METRAHEALTH RR | OTHER |