Basic Information
| Provider Information | |||||||||
| NPI: | 1952599482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETER J KIEFER MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1792 E OAKTON ST | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600182110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478274496 | ||||||||
| FaxNumber: | 8478271256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1792 E OAKTON ST | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600182110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478274496 | ||||||||
| FaxNumber: | 8478271256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | KIEFER | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | JURGEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8478274496 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36059034 | 05 | IL | MEDICAID |