MEDICARE: DR. SOGOL JAHEDI 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	207V00000X	Obstetrics & Gynecology Physician	036.120258	IL
2	207V00000X	Obstetrics & Gynecology Physician	36-120258	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36-120258	OTHER	IL	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1922265701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOGOL JAHEDI JIMENEZ MD

Provider Business Mailing Address
First Line	:	250 W KENSINGTON RD STE 1B
Second Line	:
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1292
Country	:	US
Telephone Number	:	847-568-1488
Fax Number	:	847-749-2695

Provider Business Practice Location Address
First Line	:	250 W KENSINGTON RD STE 1B
Second Line	:
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1292
Country	:	US
Telephone Number	:	847-568-1488
Fax Number	:	847-749-2695

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	06/11/2019

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