Basic Information
| Provider Information | |||||||||
| NPI: | 1174624415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHEN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35.083380 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 036133593 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | F40332641 | 01 | IL | MEDICARE INDIVID PTAN | OTHER | 206147 | 01 | IL | MEDICARE GROUP PTAN | OTHER |