Healthcare Provider Details

I. General information

NPI: 1568457455
Provider Name (Legal Business Name): LUIS ANTONIO OSORIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 W CERMAK RD
NORTH RIVERSIDE IL
60546-1405
US

IV. Provider business mailing address

5201 WILLOW SPRINGS RD STE 150
LA GRANGE HIGHLANDS IL
60525-6557
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-6338
  • Fax:
Mailing address:
  • Phone: 708-245-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36087612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: