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General NPI Number Information
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NPI Number | 1942482278
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Entity Type | Organization
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Legal Business Name | JESSE K. PARK MD SC
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Dates
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Enumeration Date | 11/28/2007
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Last Update Date | 02/28/2013
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Provider Practice Location Address
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Address Line | 100 TOWER DR SUITE 105
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City | BURR RIDGE
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State | IL
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Zip | 60527-5777
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Country | US
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Telephone | 630-325-8681
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Fax | 630-325-3936
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Provider Business Mailing Address
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Address Line | 100 TOWER DR SUITE 105
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City | BURR RIDGE
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State | IL
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Zip | 60527-5777
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Country | US
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Telephone | 630-325-8681
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Fax | 630-325-3936
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. JESSE KITAI PARK
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Credential | MD
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Telephone | 630-325-8681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 036-080235
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License Number State | IL
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