=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770526279
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAROLD JAIMES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 10/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3153 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-395-4600
-----------------------------------------------------
Fax | 773-395-4633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3153 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-395-4600
-----------------------------------------------------
Fax | 773-395-4633
-----------------------------------------------------
=====================================================
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 | 036088816
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------