1477522050 NPI number — DR. JONATHAN S. BUKA M.D.

Table of content: DR. JONATHAN S. BUKA M.D. (NPI 1477522050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477522050 NPI number — DR. JONATHAN S. BUKA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUKA
Provider First Name:
JONATHAN
Provider Middle Name:
S.
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:
1477522050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 W 95TH ST STE 312
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK LAWN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60453-2660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-581-3514
Provider Business Mailing Address Fax Number:
708-952-0329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 95TH ST STE 312
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:
60453-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-581-3514
Provider Business Practice Location Address Fax Number:
708-398-8863
Provider Enumeration Date:
03/16/2006

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: 207W00000X , with the licence number:  01053839A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 036066839 , 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: 205785 . This is a "PTAN IL MEDICARE COOK COUNTY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 253350 . This is a "PTAN GROUP PRACTICE INDIANA MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: DR4230 . This is a "MEDICARE RAILROAD GROUP PTAN DUPAGE CO." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00932946 . This is a "MEDICARE RAILROAD DUPAGE CO. INDIVIDUAL PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200325390B . This is a "IN PHYSICIANS MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200871680C . This is a "MEDICAID LOCATION ORLAND PARK" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 036066839 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180046208 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200871680A . This is a "MEDICAID LOCATION MUNSTER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200871680D . This is a "MEDICAID LOCATION HINSDALE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 205786 . This is a "PTAN IL MEDICARE DUPAGE COUNTY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 833002861 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200871680B . This is a "MEDICAID LOCATION CHICAGO RIDGE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200325390 . This is a "MEDICARE LEGACY PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: L77581 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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