Provider Demographics
NPI:1861468357
Name:MUCCINO, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MUCCINO
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 1:2160 S 1ST AVE
Mailing Address - Street 2:(LUH - NORTH ENT., RM. 7604)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-8757
Mailing Address - Fax:708-216-1259
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(LUH - NORTH ENT., RM. 7604)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-8757
Practice Address - Fax:708-216-1259
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36112339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36112339Medicaid
ILK12111OtherMEDICARE
ILK12111OtherMEDICARE
ILK12110Medicare ID - Type Unspecified