Healthcare Provider Details

I. General information

NPI: 1629290655
Provider Name (Legal Business Name): MARK E CICHON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVE EMS BLDG. RM. 2700
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S FIRST AVE EMS BLDG. RM. 2700
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-327-2700
  • Fax: 708-327-3474
Mailing address:
  • Phone: 708-327-2700
  • Fax: 708-327-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036073801
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036073801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: