Healthcare Provider Details

I. General information

NPI: 1598760480
Provider Name (Legal Business Name): MICHAEL R FIORUCCI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST SUITE 306
EVERGREEN PARK IL
60805-2735
US

IV. Provider business mailing address

2850 W 95TH ST SUITE 306
EVERGREEN PARK IL
60805-2735
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-8500
  • Fax: 708-229-6081
Mailing address:
  • Phone: 708-422-8500
  • Fax: 708-229-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47268
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036108602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: