Provider Demographics
NPI:1215498118
Name:KHIELLA, MARCO N (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:N
Last Name:KHIELLA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 JOLIET ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1705
Mailing Address - Country:US
Mailing Address - Phone:708-855-7297
Mailing Address - Fax:708-679-2161
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-852-1524
Practice Address - Fax:219-933-2288
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01090952A207R00000X, 208M00000X
IL036161213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty