Healthcare Provider Details

I. General information

NPI: 1548796683
Provider Name (Legal Business Name): JORDAN O'NEILL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE RESURRECTION FAMILY MEDICINE SUITE 182
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE RESURRECTION FAMILY MEDICINE SUITE 182
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036153746
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: