Healthcare Provider Details

I. General information

NPI: 1821731357
Provider Name (Legal Business Name): JOSEPH VICINI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 FORTUNE BLVD
O FALLON IL
62269-7358
US

IV. Provider business mailing address

1170 FORTUNE BLVD
SHILOH IL
62269-7358
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5266
  • Fax:
Mailing address:
  • Phone: 618-997-5266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125.080604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: