Provider Demographics
NPI:1447228036
Name:TRICOU, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:TRICOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E FAIRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1644
Mailing Address - Country:US
Mailing Address - Phone:815-432-7728
Mailing Address - Fax:815-432-7827
Practice Address - Street 1:200 E FAIRMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1644
Practice Address - Country:US
Practice Address - Phone:815-432-7728
Practice Address - Fax:815-432-7827
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0780292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF30562Medicare UPIN
ILL78888Medicare ID - Type UnspecifiedLOCATION - JOLIET
ILF30562Medicare UPIN