Active NPI
Michael J Blacconiere, PH.D.
- Clinical Psychologist
- Hines, IL
National Provider Identifier
1801977269
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 71004033
- Practice address
- Hines VA Hospital
5TH Ave & Roosevelt Rd
Hines, IL 60141 - Phone
- (708) 202-2656
- NPI assigned
- Oct 18, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 71004033 | IL | Primary |
Addresses
Primary practice location
Hines VA Hospital
5TH Ave & Roosevelt Rd
Hines, IL 60141
Mailing address
1339 Margret St
Des Plaines, IL 60018-1522
Phone (847) 827-6641
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 71004033 | IL | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161129600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1801977269",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1339 MARGRET ST",
"city": "DES PLAINES",
"state": "IL",
"postal_code": "600181522",
"telephone_number": "847-827-6641"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "HINES VA HOSPITAL",
"address_2": "5TH AVE & ROOSEVELT RD",
"city": "HINES",
"state": "IL",
"postal_code": "60141",
"telephone_number": "708-202-2656"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACCONIERE",
"first_name": "MICHAEL",
"middle_name": "J",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-18",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "71004033",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hines, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.