Provider Demographics
NPI:1801849559
Name:MARCUCCILLI, CHARLES J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:MARCUCCILLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE
Mailing Address - Street 2:DEPT OF PEDIATRICS, MC 3055
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-702-6487
Mailing Address - Fax:
Practice Address - Street 1:180 HARVESTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7594
Practice Address - Country:US
Practice Address - Phone:773-702-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI487362084N0400X
IL0361022742084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34818000Medicaid
0005T73601Medicare ID - Type Unspecified
WI34818000Medicaid