Basic Information
| Provider Information | |||||||||
| NPI: | 1205896008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISOCCO | ||||||||
| FirstName: | LORIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 580 E BOUGHTON RD | ||||||||
| Address2: | STE A | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604402565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
| FaxNumber: | 6304951770 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 RIVER OAKS DR | ||||||||
| Address2: | |||||||||
| City: | CALUMET CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088621290 | ||||||||
| FaxNumber: | 7088626447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 036054667 | IL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 200015120A | 05 | IL | MEDICAID |