Provider Demographics
NPI:1811123433
Name:FAZIO, MICHAEL GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:FAZIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:618-257-5613
Mailing Address - Fax:314-454-4641
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-257-5613
Practice Address - Fax:314-454-4641
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361515502085R0202X
390200000X
IADO-048722085R0202X
MO20200128002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200085569Medicaid