Provider Demographics
NPI:1497866198
Name:MAGNO MEDICAL LLC
Entity Type:Organization
Organization Name:MAGNO MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:O
Authorized Official - Last Name:MAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-736-1500
Mailing Address - Street 1:8315 VIRGINIA ST
Mailing Address - Street 2:SUITE M
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6238
Mailing Address - Country:US
Mailing Address - Phone:219-736-1500
Mailing Address - Fax:219-736-1551
Practice Address - Street 1:8315 VIRGINIA ST
Practice Address - Street 2:SUITE M
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6238
Practice Address - Country:US
Practice Address - Phone:219-736-1500
Practice Address - Fax:219-736-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054491A207Q00000X
IN010360352084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN193220Medicare ID - Type Unspecified