Healthcare Provider Details

I. General information

NPI: 1386638310
Provider Name (Legal Business Name): JACKSON THOMAS NORMAN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHILDREN'S PLAZA CHILDREN'S MEMORIAL HOSPITAL
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

2300 CHILDREN'S PLAZA CHILDREN'S MEMORIAL HOSPITAL
CHICAGO IL
60614-3363
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-6792
  • Fax: 773-880-3517
Mailing address:
  • Phone: 773-880-6792
  • Fax: 773-880-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036-095998
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-095998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: