Provider Demographics
NPI:1184759136
Name:CACIOPPO, PHILLIP LEON (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LEON
Last Name:CACIOPPO
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 1:800 BIESTERFIELD RD
Mailing Address - Street 2:WIMMER BLDG. SUITE 202
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3311
Mailing Address - Country:US
Mailing Address - Phone:847-806-0106
Mailing Address - Fax:847-806-9323
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:WIMMER BLDG. SUITE 202
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3311
Practice Address - Country:US
Practice Address - Phone:847-806-0106
Practice Address - Fax:847-806-9323
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31602106OtherBLUE SHIELD
IL0361047981Medicaid
IL461632OtherMEDICARE
IL31602106OtherBLUE SHIELD
ILC41515Medicare UPIN