MEDICARE: DR. JUAN C. JIMENEZ 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	207T00000X	Neurological Surgery Physician	036103254	IL

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	4632039	OTHER	IL	BC GROUP NUMBER

General Provider Information

NPI Number	:	1801992516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN C. JIMENEZ MD

Provider Business Mailing Address
First Line	:	400 N WALL ST
Second Line	:	SUITE 402
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2940
Country	:	US
Telephone Number	:	815-932-7200
Fax Number	:	815-935-7874

Provider Business Practice Location Address
First Line	:	400 N WALL ST
Second Line	:	SUITE 402
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2940
Country	:	US
Telephone Number	:	815-932-7200
Fax Number	:	815-935-7874

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	03/22/2021

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