Healthcare Provider Details

I. General information

NPI: 1952126989
Provider Name (Legal Business Name): JINOR OSI GWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date: 06/17/2025
Reactivation Date: 07/28/2025

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

7714 24TH AVE
EAST ELMHURST NY
11370-1518
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 910-337-8299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.086786
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: