Provider Demographics
NPI:1952436941
Name:PHILLIP L CACIOPPO MD SC
Entity Type:Organization
Organization Name:PHILLIP L CACIOPPO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:CACIOPPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-806-0106
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360417401Medicaid
IL31602106OtherBLUE SHIELD
IL461632Medicare ID - Type Unspecified
IL0360417401Medicaid