Individual
JOHN PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2917 CROSSING CT, SUITE B1, CHAMPAIGN, IL 61822-6184
(217) 344-2740
(217) 344-2819
Mailing address
2917 CROSSING CT, SUITE B1, CHAMPAIGN, IL 61822-6184
(217) 344-2740
(217) 344-2819
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
036083081
IL
207R00000X
Internal Medicine Physician
Primary
036083081
IL
207RA0401X
Addiction Medicine (Internal Medicine) Physician
036083081
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036083081
—
IL
Enumeration date
07/17/2006
Last updated
03/16/2019
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