Healthcare Provider Details

I. General information

NPI: 1417973116
Provider Name (Legal Business Name): JEFFREY WAYNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR SUITE 1000
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 1000
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-4022
  • Fax:
Mailing address:
  • Phone: 312-695-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: