Provider Demographics
NPI:1033159157
Name:SCARAMELLA, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:SCARAMELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7389
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-7389
Mailing Address - Country:US
Mailing Address - Phone:847-870-3600
Mailing Address - Fax:847-870-3500
Practice Address - Street 1:4920 N CENTRAL AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2338
Practice Address - Country:US
Practice Address - Phone:773-202-5959
Practice Address - Fax:773-202-9144
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087838Medicaid
IL519010Medicare PIN
IL036087838Medicaid