Provider Demographics
NPI:1538233176
Name:PETERSON, MARY (DC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 W COLLEGE DR
Mailing Address - Street 2:SUITE 1SW
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1151
Mailing Address - Country:US
Mailing Address - Phone:708-371-6114
Mailing Address - Fax:708-371-0816
Practice Address - Street 1:7250 W COLLEGE DR
Practice Address - Street 2:SUITE 1SW
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1151
Practice Address - Country:US
Practice Address - Phone:708-371-6114
Practice Address - Fax:708-371-0816
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007900111N00000X
VA0104556711111N00000X
IL212.000204224L00000X
IL038.008605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G010660OtherBCBS
MI950G010660OtherBCBS
MIN94490001Medicare ID - Type Unspecified