1245369685 NPI number — DR. JORGE ENRIQUE BALANDRIN M.D.

Table of content: DR. JORGE ENRIQUE BALANDRIN M.D. (NPI 1245369685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245369685 NPI number — DR. JORGE ENRIQUE BALANDRIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALANDRIN
Provider First Name:
JORGE
Provider Middle Name:
ENRIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1245369685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10621 PALOS WEST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60464-1598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-448-1476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 W 95TH ST STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-2572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-424-1222
Provider Business Practice Location Address Fax Number:
708-229-2355
Provider Enumeration Date:
03/03/2007

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: 207R00000X , with the licence number:  036070483 , 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)





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