Basic Information
| Provider Information | |||||||||
| NPI: | 1063599744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NG | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HSIEH | ||||||||
| OtherFirstName: | JENNIE | ||||||||
| OtherMiddleName: | NG | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1026 ALEXANDER LN | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603024444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088480516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 TRANSAM PLAZA DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601814289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307172600 | ||||||||
| FaxNumber: | 6309323437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 036-111351 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1622295 | 01 | IL | BCBS | OTHER | 0361111351 | 05 | IL | MEDICAID |