Provider Demographics
NPI:1528196656
Name:FUMO, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:FUMO
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 1:351 EXECUTIVE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5339
Mailing Address - Country:US
Mailing Address - Phone:815-398-4057
Mailing Address - Fax:
Practice Address - Street 1:351 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5339
Practice Address - Country:US
Practice Address - Phone:815-398-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117800208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117800Medicaid
IL0330930001Medicare NSC