Basic Information
| Provider Information | |||||||||
| NPI: | 1023223021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEACOCK | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N. LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1333 W BELMONT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126942273 | ||||||||
| FaxNumber: | 3126941875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200700 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 036.141382 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 200700 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 036.141382 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05024018 | 05 | MS | MEDICAID | 1073849 | 05 | LA | MEDICAID |