MEDICARE: IAN GREG JASENOF 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	207V00000X	Obstetrics & Gynecology Physician	036083005	IL

General Provider Information

NPI Number	:	1578509428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN GREG JASENOF M.D.

Provider Business Mailing Address
First Line	:	1220 S WOOD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1202
Country	:	US
Telephone Number	:	312-413-3282
Fax Number	:

Provider Business Practice Location Address
First Line	:	1220 S WOOD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1202
Country	:	US
Telephone Number	:	312-413-1453
Fax Number	:

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

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	10/30/2023

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