=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356568695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON CORDELL BIRNHOLZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 OAKBROOK CTR SUITE 408
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-954-5577
-----------------------------------------------------
Fax | 630-954-2919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 OAKBROOK CTR SUITE 408
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-954-5577
-----------------------------------------------------
Fax | 630-954-2919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | 36-065383
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------