Provider Demographics
NPI:1093768004
Name:CASCO, MYRLIE LARENA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MYRLIE
Middle Name:LARENA
Last Name:CASCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3512
Mailing Address - Country:US
Mailing Address - Phone:847-325-5110
Mailing Address - Fax:847-325-5114
Practice Address - Street 1:1105 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3512
Practice Address - Country:US
Practice Address - Phone:847-325-5110
Practice Address - Fax:847-325-5114
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056767Medicaid
IL213558Medicare PIN
ILE19340Medicare UPIN
ILL34844Medicare ID - Type Unspecified