Healthcare Provider Details

I. General information

NPI: 1720494396
Provider Name (Legal Business Name): JOSEPH DEBARTOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHERMAN HOSPITAL 1425 N. RANDALL RD
ELGIN ILLINOIS
60123
UM

IV. Provider business mailing address

1425 N RANDALL RD DEPARTMENT OF RADIOLOGY
ELGIN IL
60123-2300
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-8098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036143450
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125.065443
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.065443
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: