Provider Demographics
NPI:1467773036
Name:TALLARICO, MICHAEL VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:TALLARICO
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 1:1001 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1596
Mailing Address - Country:US
Mailing Address - Phone:219-924-7178
Mailing Address - Fax:219-924-8179
Practice Address - Street 1:1001 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311
Practice Address - Country:US
Practice Address - Phone:219-924-8178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058221207R00000X
IN01078614A207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine