Provider Demographics
NPI:1760587869
Name:COCCARO, GREGG S (MD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:S
Last Name:COCCARO
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 1:1423 CHICAGO RD
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3400
Mailing Address - Country:US
Mailing Address - Phone:708-756-1000
Mailing Address - Fax:
Practice Address - Street 1:1423 CHICAGO RD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3400
Practice Address - Country:US
Practice Address - Phone:708-756-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360855522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
131719100OtherDEPARTMENT OF LABOR
IL036085552Medicaid
L022428OtherCHAMPUS
300050047OtherRAILROAD ID
078631OtherHEALTH ALLIANCE
IL1618334OtherBCBS ID
078631OtherHEALTH ALLIANCE
L38040Medicare PIN
300050047OtherRAILROAD ID
ILK45407Medicare PIN