Provider Demographics
NPI:1003915166
Name:CALUMET DERMATOLOGY ASSOC S C
Entity Type:Organization
Organization Name:CALUMET DERMATOLOGY ASSOC S C
Other - Org Name:LORIS A TISOCCO MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-862-1290
Mailing Address - Street 1:19 RIVER OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409
Mailing Address - Country:US
Mailing Address - Phone:708-862-1290
Mailing Address - Fax:708-862-6447
Practice Address - Street 1:19 RIVER OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409
Practice Address - Country:US
Practice Address - Phone:708-862-1290
Practice Address - Fax:708-862-6447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000239604OtherANTHEM BCBS OF INDIANA
IL333920Medicare PIN
IN409160Medicare PIN