Healthcare Provider Details

I. General information

NPI: 1689889412
Provider Name (Legal Business Name): MICHAEL ALBERT PANOZZO RFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ALMAR PKWY SUITE 205
BOURBONNAIS IL
60914-2315
US

IV. Provider business mailing address

1105 KERRY LN
JOLIET IL
60431-8648
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-3955
  • Fax: 815-933-3944
Mailing address:
  • Phone: 815-254-7065
  • Fax: 815-933-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: