Provider Demographics
NPI:1205896008
Name:TISOCCO, LORIS A (MD)
Entity type:Individual
Prefix:
First Name:LORIS
Middle Name:A
Last Name:TISOCCO
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 1:580 E BOUGHTON RD
Mailing Address - Street 2:STE A
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2565
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:19 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409
Practice Address - Country:US
Practice Address - Phone:708-862-1290
Practice Address - Fax:708-862-6447
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054667207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200015120AMedicaid
IN409160Medicare PIN
IL493030Medicare ID - Type Unspecified
IL200015120AMedicaid