Healthcare Provider Details

I. General information

NPI: 1861426223
Provider Name (Legal Business Name): ALAN MICCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 15-200
CHICAGO IL
60611-5967
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 15-200
CHICAGO IL
60611-5967
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8182
  • Fax: 312-695-4303
Mailing address:
  • Phone: 312-695-8182
  • Fax: 312-695-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036079904
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number036-079904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: