Healthcare Provider Details

I. General information

NPI: 1144859406
Provider Name (Legal Business Name): JACQUELINE ANNE URBAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 730
CHICAGO IL
60611-2990
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 730
CHICAGO IL
60611-2990
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0070
  • Fax: 312-926-0239
Mailing address:
  • Phone: 312-695-0070
  • Fax: 312-926-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.163726
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTL.0008165
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: