MEDICARE: DR. GLENN FRANCIS SUACILLO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician		IL

General Provider Information

NPI Number	:	1780620781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN FRANCIS SUACILLO D.O.

Provider Business Mailing Address
First Line	:	2065 CHATHAM DR
Second Line	:
City	:	WHEATON
State	:	IL
Zip	:	60187-8160
Country	:	US
Telephone Number	:	630-784-9893
Fax Number	:	630-784-9893

Provider Business Practice Location Address
First Line	:	25 N WINFIELD RD
Second Line	:
City	:	WINFIELD
State	:	IL
Zip	:	60190-1222
Country	:	US
Telephone Number	:	630-933-2600
Fax Number	:	630-922-1234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	11/16/2007

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