MEDICARE: DR. SIDDHARTH JAIN MD

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	208000000X	Pediatrics Physician	2014012628	MO
2	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	61086	AZ
3	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	2014012628	MO
4	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	C1118	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588847529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIDDHARTH JAIN MD

Provider Business Mailing Address
First Line	:	411 E CHESTNUT ST # 6
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1713
Country	:	US
Telephone Number	:	502-588-3650
Fax Number	:

Provider Business Practice Location Address
First Line	:	1432 S DOBSON RD STE 403
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-4777
Country	:	US
Telephone Number	:	480-412-7473
Fax Number	:

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

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	12/20/2022

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