Provider Demographics
NPI:1851367270
Name:MAGLIETTA, EDWARD D (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:MAGLIETTA
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 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4030
Mailing Address - Country:US
Mailing Address - Phone:815-599-7958
Mailing Address - Fax:
Practice Address - Street 1:1036 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4865
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38329Medicare UPIN
ILL65390Medicare ID - Type Unspecified