Provider Demographics
NPI:1841297447
Name:PISCOPO, PHILLIP W (DC)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:W
Last Name:PISCOPO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1911
Mailing Address - Country:US
Mailing Address - Phone:708-672-5761
Mailing Address - Fax:708-672-4048
Practice Address - Street 1:1018 MAIN ST
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-1911
Practice Address - Country:US
Practice Address - Phone:708-672-5761
Practice Address - Fax:708-672-4048
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL248690Medicare ID - Type Unspecified
ILT35565Medicare UPIN