Healthcare Provider Details

I. General information

NPI: 1164878781
Provider Name (Legal Business Name): JAIRUS JAMES LUKOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 HASSELL RD
HOFFMAN ESTATES IL
60169-2102
US

IV. Provider business mailing address

1860 PAYSPHERE CIR
CHICAGO IL
60674-2315
US

V. Phone/Fax

Practice location:
  • Phone: 847-843-7030
  • Fax:
Mailing address:
  • Phone: 630-469-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125068300
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.148172
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: