Healthcare Provider Details

I. General information

NPI: 1992769822
Provider Name (Legal Business Name): GUY AGOSTINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 W BURLINGTON AVE SUITE 100
LA GRANGE IL
60525-2221
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 630-390-1240
  • Fax: 630-390-1247
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036075612
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036075612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: