Basic Information
| Provider Information | |||||||||
| NPI: | 1346747292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONSECA-PARICIO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 HARVESTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605274503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5841 S. MARYLAND AVE | ||||||||
| Address2: | M/C 6076 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737029660 | ||||||||
| FaxNumber: | 7738347068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2018 | ||||||||
| LastUpdateDate: | 06/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 036.156755 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0200X | 036.156755 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1346747292 | 05 | PA | MEDICAID | 036.156755 | 01 | IL | STATE OF ILLINOIS | OTHER |