Healthcare Provider Details

I. General information

NPI: 1083816391
Provider Name (Legal Business Name): LEONARDO FAORO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE MC2115
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

5841 S MARYLAND AVE MC2115
CHICAGO IL
60637-1447
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-1675
  • Fax: 773-702-3163
Mailing address:
  • Phone: 773-834-1675
  • Fax: 773-702-3163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number36113843
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: