Provider Demographics
NPI:1225020142
Name:MAGNANAO, ULYSSES M (DO)
Entity Type:Individual
Prefix:DR
First Name:ULYSSES
Middle Name:M
Last Name:MAGNANAO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1710 N RANDALL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-9400
Mailing Address - Country:US
Mailing Address - Phone:847-214-5740
Mailing Address - Fax:847-214-5777
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:847-214-5780
Practice Address - Fax:847-214-5777
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2021-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036105671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619414OtherBCBS GROUP
IL612034800OtherIL DEPT OF LABOR
IL036105671Medicaid
IL05632414OtherBCBS PROV #
ILP01117452OtherRAILROAD MEDICARE PTAN
IL05632168OtherBLUE CROSS & BLUE SHIELD
ILP00323126Medicare PIN
ILIL2304002Medicare PIN
IL212688Medicare PIN
IL1619414OtherBCBS GROUP
ILP01117452OtherRAILROAD MEDICARE PTAN
IL213035Medicare PIN
ILK17211ICCMedicare PIN
IL05632414OtherBCBS PROV #
IL036105671Medicaid
ILIL2305002Medicare PIN
IL05632168OtherBLUE CROSS & BLUE SHIELD
ILIL7412Medicare UPIN