=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760175129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGGIOLINO MEDICAL, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2023
-----------------------------------------------------
Last Update Date | 06/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 S WAUKEGAN RD STE 102
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-514-9297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 S WAUKEGAN RD STE 102
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-514-9297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARY DANA FOGGETTI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 630-514-9297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------