Healthcare Provider Details

I. General information

NPI: 1205896008
Provider Name (Legal Business Name): LORIS A TISOCCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 RIVER OAKS DR
CALUMET CITY IL
60409
US

IV. Provider business mailing address

580 E BOUGHTON RD STE A
BOLINGBROOK IL
60440-2565
US

V. Phone/Fax

Practice location:
  • Phone: 708-862-1290
  • Fax: 708-862-6447
Mailing address:
  • Phone: 815-744-8554
  • Fax: 630-495-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036054667
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: