Provider Demographics
NPI:1972607497
Name:MONACO, MARY ELLEN (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MONACO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:79 129TH INFANTRY DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5134
Mailing Address - Country:US
Mailing Address - Phone:815-730-1541
Mailing Address - Fax:815-744-8632
Practice Address - Street 1:79 129TH INFANTRY DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5134
Practice Address - Country:US
Practice Address - Phone:815-730-1541
Practice Address - Fax:815-744-8632
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360969282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096928Medicaid
ILG96466Medicare UPIN
IL951230Medicare PIN