Provider Demographics
NPI:1730382201
Name:CRIVELLARO, SIMONE (MD)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:CRIVELLARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-9331
Mailing Address - Fax:
Practice Address - Street 1:820 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00873208800000X
IL036174667208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ73007Medicaid
NC5907682Medicaid
NCAETNAOther9286104
VA1730382201Medicaid
NC202774OtherMEDCOST
NC147F0OtherBCBS
WV3810009657Medicaid
NC812200OtherPARTNERS
NC812200OtherPARTNERS
NCP00416740Medicare PIN