MEDICARE: JACK C. ENTER JR. PA-C

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	363A00000X	Physician Assistant	085-000925	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	085.000925	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1366444184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK C. ENTER JR. PA-C

Provider Business Mailing Address
First Line	:	10100 FOREST HILLS RD
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-8234
Country	:	US
Telephone Number	:	815-713-2742
Fax Number	:	815-282-8597

Provider Business Practice Location Address
First Line	:	4211 N CICERO AVE
Second Line	:	SUITE 100
City	:	CHICAGO
State	:	IL
Zip	:	60641-1651
Country	:	US
Telephone Number	:	773-794-1000
Fax Number	:	773-794-9986

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	10/17/2008

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