Healthcare Provider Details

I. General information

NPI: 1831647205
Provider Name (Legal Business Name): MARCELO ROCHA DE SOUSA CRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 EAST SUPERIOR STREET 1ST FLOOR
CHICAGO IL
60611
US

IV. Provider business mailing address

233 EAST SUPERIOR STREET, SUITE 01-023
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-1234
  • Fax: 312-472-0574
Mailing address:
  • Phone: 312-472-1234
  • Fax: 312-472-0564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number125069681
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: