Healthcare Provider Details

I. General information

NPI: 1215996301
Provider Name (Legal Business Name): PANKAJ JAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 203RD ST SUITE 202
OLYMPIA FIELDS IL
60461-1184
US

IV. Provider business mailing address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7240
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2660
  • Fax: 708-503-3861
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number39423
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036121222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: