Healthcare Provider Details

I. General information

NPI: 1902369689
Provider Name (Legal Business Name): JEREMIAH JOHN COMBS LOCQUIAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W COURT ST
KANKAKEE IL
60901-3691
US

IV. Provider business mailing address

1020 SANSOM ST STE 1651B
PHILADELPHIA PA
19107-5002
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-2100
  • Fax:
Mailing address:
  • Phone: 215-955-9837
  • Fax: 215-955-9870

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 State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036159040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: