Healthcare Provider Details

I. General information

NPI: 1548964513
Provider Name (Legal Business Name): JEROME YOSHIO TUTTLE-ROACHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
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: 312-227-4322
  • Fax:
Mailing address:
  • Phone: 312-227-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036.180906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: