Basic Information
| Provider Information | |||||||||
| NPI: | 1902291644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9650 GROSS POINT RD. SUITE 2900 | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478667846 | ||||||||
| FaxNumber: | 2242512905 | ||||||||
| Practice Location | |||||||||
| Address1: | 9650 GROSS POINT RD. SUITE 2900 | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478667846 | ||||||||
| FaxNumber: | 2242512905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036150318 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 036150318 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.