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General NPI Number Information
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NPI Number | 1093507162
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Entity Type | Individual
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Provider Name | JAISON PAUL MD
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Gender | Male
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 8201 E RIVERSIDE BLVD
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City | ROCKFORD
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State | IL
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Zip | 61114-2300
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Country | US
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Telephone | 815-971-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 7702 N ALPINE RD
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City | LOVES PARK
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State | IL
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Zip | 61111-3107
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Country | US
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Telephone | 815-971-3397
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 125.085838
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License Number State | IL
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