=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194821769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERMIT LIONEL JONES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 W VAN BUREN ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-563-2875
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 S SANGAMON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-274-5793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036139808
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------