Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 036-061024 | IL |
NPI | 1164431391 |
---|---|
Provider Name | Peter Baum |
First Address | Sycamore, IL 60178-3192 |
Second Address | Sycamore, IL 60178-3192 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2006 |
Last Update Date | 28/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008447 | HEALTH ALLIANCE (01) | IL |
036061024 | (05) | IL |
D15424 | (02) | IL |