Basic Information
| Provider Information | |||||||||
| NPI: | 1023240470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN C TRICOU MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9410 COMPUBILL DR | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604622627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084607444 | ||||||||
| FaxNumber: | 7084608662 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E FAIRMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154325841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2009 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | TRICOU | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7084607444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 036078029 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085U0001X | 036078029 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 036078029 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036078029 | 05 | IL | MEDICAID |