Healthcare Provider Details

I. General information

NPI: 1871293712
Provider Name (Legal Business Name): MARC CALABRIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E LAKE ST STE A
BLOOMINGDALE IL
60108-1163
US

IV. Provider business mailing address

1 TIFFANY PT STE G11
BLOOMINGDALE IL
60108-2961
US

V. Phone/Fax

Practice location:
  • Phone: 708-369-6272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036139322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: