MEDICARE: JACK R CHAMBERLIN M.D.

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	207RC0000X	Cardiovascular Disease Physician	036086925	IL
2	207RI0011X	Interventional Cardiology Physician	036-086925	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IL6305015	OTHER	IL	MEDICARE PTAN LOC 15
3	IL6304015	OTHER	IL	MEDICARE PTAN LOC 16

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1720371669	OTHER	IL	NPI GROUP PRACTICE
4	P01008734	OTHER	IL	RRMC PTAN

General Provider Information

NPI Number	:	1215980321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK R CHAMBERLIN M.D.

Provider Business Mailing Address
First Line	:	900 S FRONTAGE RD
Second Line	:	SUITE 325
City	:	WOODRIDGE
State	:	IL
Zip	:	60517-4903
Country	:	US
Telephone Number	:	847-981-3680
Fax Number	:	847-956-5122

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD STE G01
Second Line	:	WIMMER BUILDING
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3372
Country	:	US
Telephone Number	:	847-981-3680
Fax Number	:	847-956-5122

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	04/10/2015

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Directions to “ JACK R CHAMBERLIN M.D.” Practice Location

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