Healthcare Provider Details

I. General information

NPI: 1346654308
Provider Name (Legal Business Name): CHIEN-JUNG LIN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY STE 305
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY STE 305
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-6277
  • Fax: 618-474-6792
Mailing address:
  • Phone: 618-474-6277
  • Fax: 618-474-6792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2014014716
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2017028726
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036164062
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2017028726
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: