Healthcare Provider Details

I. General information

NPI: 1639291297
Provider Name (Legal Business Name): MARCO ANTONIO GUERRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 W 21ST ST
CHICAGO IL
60608-4511
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax: 773-650-1239
Mailing address:
  • Phone: 773-254-1400
  • Fax: 773-650-1239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036076861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: