MEDICARE: DR. JASON GHODASRA 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	207XS0106X	Orthopaedic Hand Surgery Physician	036-150218	IL

General Provider Information

NPI Number	:	1316280159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON GHODASRA M.D.

Provider Business Mailing Address
First Line	:	1870 SILVER CROSS BLVD STE 200
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-8646
Country	:	US
Telephone Number	:	815-462-3474
Fax Number	:

Provider Business Practice Location Address
First Line	:	1870 SILVER CROSS BLVD STE 200
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-8646
Country	:	US
Telephone Number	:	815-462-3474
Fax Number	:	815-462-1032

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

Provider Enumeration Date	:	03/29/2013
Last Update Date	:	12/14/2022

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