=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265576722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BHAGWAN D JAIN MDSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2007
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 W IRVING PARK RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-975-6772
-----------------------------------------------------
Fax | 773-935-2928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6401 MEADOW LN
-----------------------------------------------------
City | WILLOWBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60527-5414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-226-0846
-----------------------------------------------------
Fax | 630-679-0052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BHAGWAN D JAIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-975-6772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 036052307
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------