Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | IL |
NPI | 1205973690 |
---|---|
Provider Name | Dr. Louis B. Scannicchio |
First Address | Oak Park, IL 60301-1304 |
Second Address | Oak Park, IL 60301-1304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10535 | BCBS (01) | IL |
T38647 | (02) | IL |