MEDICARE: BAILAN JIN D.N.

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	174400000X	Specialist	181-000303	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01633495	OTHER	IL	BLUESHIELD PROVIDER NUMBE
2	181-000303	OTHER	IL	LICENSE NUMBER

General Provider Information

NPI Number	:	1669546685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAILAN JIN D.N.

Provider Business Mailing Address
First Line	:	2165 S CHINA PL
Second Line	:	SUITE B
City	:	CHICAGO
State	:	IL
Zip	:	60616-1536
Country	:	US
Telephone Number	:	773-386-2683
Fax Number	:	312-225-4047

Provider Business Practice Location Address
First Line	:	2165 S CHINA PL
Second Line	:	SUITE B
City	:	CHICAGO
State	:	IL
Zip	:	60616-1536
Country	:	US
Telephone Number	:	773-386-2683
Fax Number	:	312-225-4047

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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