MEDICARE: JORDAN B PRITIKIN 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	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	036087346	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	040017908	OTHER	IL	RRMC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770585259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN B PRITIKIN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-0160
Country	:	US
Telephone Number	:	708-747-5850
Fax Number	:	708-747-9991

Provider Business Practice Location Address
First Line	:	111 W WASHINGTON ST
Second Line	:	SUITE 903
City	:	CHICAGO
State	:	IL
Zip	:	60602-2703
Country	:	US
Telephone Number	:	312-372-9355
Fax Number	:	312-372-9356

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	09/14/2023

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