Basic Information
| Provider Information | |||||||||
| NPI: | 1568566156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOIACONO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 207 ELK AVE S | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373343051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314332551 | ||||||||
| FaxNumber: | 9314380069 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 ELK AVE S | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373343051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314332551 | ||||||||
| FaxNumber: | 9314380069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036073847 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 61355 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036073847 | 05 | IL | MEDICAID |