Healthcare Provider Details

I. General information

NPI: 1497866198
Provider Name (Legal Business Name): MAGNO MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8315 VIRGINIA ST SUITE M
MERRILLVILLE IN
46410-6238
US

IV. Provider business mailing address

8315 VIRGINIA ST SUITE M
MERRILLVILLE IN
46410-6238
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-1500
  • Fax: 219-736-1551
Mailing address:
  • Phone: 219-736-1500
  • Fax: 219-736-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01036035
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01054491A
License Number StateIN

VIII. Authorized Official

Name: DR. FAUSTO O MAGNO
Title or Position: CO-OWNER
Credential: M.D.
Phone: 219-736-1500