Individual
KEITH MUCCINO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2160 S 1ST AVE, (LUH - NORTH ENT., RM. 7604), MAYWOOD, IL 60153-3328
(708) 216-8757
(708) 216-1259
Mailing address
2160 S 1ST AVE, (LUH - NORTH ENT., RM. 7604), MAYWOOD, IL 60153-3328
(708) 216-8757
(708) 216-1259
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
36112339
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36112339
—
IL
01
—
K12111
MEDICARE
IL
Enumeration date
02/24/2006
Last updated
01/08/2010
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