Basic Information
| Provider Information | |||||||||
| NPI: | 1619989688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIANNOTTI | ||||||||
| FirstName: | GIOVANNI | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIANNOTTI | ||||||||
| OtherFirstName: | GIOVANNI | ||||||||
| OtherMiddleName: | DAVID | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2222 W DIVISION ST | ||||||||
| Address2: | STE 335 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606222995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735532 | ||||||||
| Practice Location | |||||||||
| Address1: | 5140 N CALIFORNIA AVE | ||||||||
| Address2: | SUITE 780 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732736810 | ||||||||
| FaxNumber: | 7732735532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 036098872 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | 036098872 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0001630046 | 01 | IL | BCBS OF IL GROUP NUMBER | OTHER | 036098872 3 | 05 | IL | MEDICAID | 036098872 2 | 05 | IL | MEDICAID |