=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255748075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIE YU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2014
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOSPITAL LN STE 120
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46122-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-745-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 W. HARRISON
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-6000
-----------------------------------------------------
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 | 125065098
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 01085371A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------