1255325676 NPI number — DR. JEROME ANTOUN JABBOUR MD

Table of content: DR. JEROME ANTOUN JABBOUR MD (NPI 1255325676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255325676 NPI number — DR. JEROME ANTOUN JABBOUR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JABBOUR
Provider First Name:
JEROME
Provider Middle Name:
ANTOUN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255325676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 N MCCLURG CT
Provider Second Line Business Mailing Address:
3806 A
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-3044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-802-3842
Provider Business Mailing Address Fax Number:
248-802-3842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 YORK ST
Provider Second Line Business Practice Location Address:
SUITE 2 C
Provider Business Practice Location Address City Name:
BLUE ISLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60406-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-809-3622
Provider Business Practice Location Address Fax Number:
773-409-8659
Provider Enumeration Date:
08/31/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01060708A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036119492 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200525220 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".