Healthcare Provider Details

I. General information

NPI: 1326612052
Provider Name (Legal Business Name): JARED MADDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 RIDGE AVE
EVANSTON IL
60202-3328
US

IV. Provider business mailing address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

V. Phone/Fax

Practice location:
  • Phone: 847-316-4000
  • Fax:
Mailing address:
  • Phone: 312-924-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1326612052
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125078515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: