Healthcare Provider Details

I. General information

NPI: 1538478565
Provider Name (Legal Business Name): JESSICA LUE-LAI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N LASALLE STREET SUITE 100
CHICAGO IL
60654
US

IV. Provider business mailing address

1931 N HALSTED ST
CHICAGO IL
60614-5008
US

V. Phone/Fax

Practice location:
  • Phone: 312-219-2231
  • Fax: 312-219-2239
Mailing address:
  • Phone: 312-219-2231
  • Fax: 312-219-2239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number100669
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036141109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: