Provider Demographics
NPI:1184606758
Name:HAGGERTY, STEPHEN PETER (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PETER
Last Name:HAGGERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 PARK AVE W
Mailing Address - Street 2:SUITE 320
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2400
Mailing Address - Country:US
Mailing Address - Phone:847-433-1060
Mailing Address - Fax:847-433-1399
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 320
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-433-1060
Practice Address - Fax:847-433-1399
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093013208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093013Medicaid
IL547720Medicare ID - Type Unspecified