Provider Demographics
NPI:1598760480
Name:FIORUCCI, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:FIORUCCI
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 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-422-8500
Mailing Address - Fax:708-229-6081
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-422-8500
Practice Address - Fax:708-229-6081
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47268208600000X
IL036108602208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34584700Medicaid
IL729903026Medicare PIN
WI0156Medicare PIN
WI34584700Medicaid