Healthcare Provider Details

I. General information

NPI: 1730499518
Provider Name (Legal Business Name): MICHAEL ANTHONY PUISIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SOUTH CALIFORNIA
CHICAGO IL
60608-5107
US

IV. Provider business mailing address

932 WESLEY
EVANSTON IL
60202
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-3658
  • Fax:
Mailing address:
  • Phone: 773-869-5641
  • Fax: 773-869-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036068255
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: