MEDICARE: JACK M LEVINE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	036-105772	IL

General Provider Information

NPI Number	:	1164492922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK M LEVINE DO

Provider Business Mailing Address
First Line	:	7428 STATE ROUTE 772
Second Line	:
City	:	PIKETON
State	:	OH
Zip	:	45661-9602
Country	:	US
Telephone Number	:	740-493-1979
Fax Number	:

Provider Business Practice Location Address
First Line	:	7428 STATE ROUTE 772
Second Line	:
City	:	PIKETON
State	:	OH
Zip	:	45661-9602
Country	:	US
Telephone Number	:	740-493-1979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	05/28/2008

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