Healthcare Provider Details

I. General information

NPI: 1487040929
Provider Name (Legal Business Name): JILLIAN ANNE DIBIASE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-5170
  • Fax: 312-227-9730
Mailing address:
  • Phone: 312-227-5170
  • Fax: 312-227-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.152344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: