Healthcare Provider Details

I. General information

NPI: 1891883773
Provider Name (Legal Business Name): JEROME T DALY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SILVER CROSS BLVD STE 265
NEW LENOX IL
60451-9623
US

IV. Provider business mailing address

1890 SILVER CROSS BLVD STE 265
NEW LENOX IL
60451-9623
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-8806
  • Fax:
Mailing address:
  • Phone: 815-727-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036-057011
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036057011
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: