Healthcare Provider Details

I. General information

NPI: 1750538260
Provider Name (Legal Business Name): JORDAN CAMERON TASSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE DEPARTMENT OF RADIOLOGY
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

1455 N SANDBURG TER #2303
CHICAGO IL
60610-1566
US

V. Phone/Fax

Practice location:
  • Phone: 847-422-3414
  • Fax:
Mailing address:
  • Phone: 847-422-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036126736
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036126736
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: