Provider Demographics
NPI:1801082870
Name:MICHAEL DESTEFANO M.D. S.C.
Entity type:Organization
Organization Name:MICHAEL DESTEFANO M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DESTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-214-9281
Mailing Address - Street 1:12504 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1851
Mailing Address - Country:US
Mailing Address - Phone:708-214-9281
Mailing Address - Fax:708-361-2742
Practice Address - Street 1:7000 W 111TH ST
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-1851
Practice Address - Country:US
Practice Address - Phone:708-214-9281
Practice Address - Fax:708-361-2742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C44248Medicare UPIN