MEDICARE: DR. JEREMY DWAINE DAIGLE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036130545	IL

General Provider Information

NPI Number	:	1558694059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY DWAINE DAIGLE M.D.

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-2600
Country	:	US
Telephone Number	:	847-390-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 W 95TH ST STE 210
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2793
Country	:	US
Telephone Number	:	312-949-4200
Fax Number	:	708-423-1899

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	06/13/2022

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