=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427035815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALAJA V. PISKA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2005
-----------------------------------------------------
Last Update Date | 11/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10095 W LINCOLN HWY
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-806-0400
-----------------------------------------------------
Fax | 815-806-0406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10095 W LINCOLN HWY
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-1272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-806-0400
-----------------------------------------------------
Fax | 815-806-0406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 036-104071
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 036104071
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------