Healthcare Provider Details

I. General information

NPI: 1316338072
Provider Name (Legal Business Name): JONATHAN M LEVINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 800
CHICAGO IL
60611-2978
US

IV. Provider business mailing address

17 HOPE ST
AUBURNDALE MA
02466-2912
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-3738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036169361
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036.169361
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA176639
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.072437
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: