Basic Information
| Provider Information | |||||||||
| NPI: | 1013950476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMAL | ||||||||
| FirstName: | ASAD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855629 | ||||||||
| FaxNumber: | 8152855634 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855629 | ||||||||
| FaxNumber: | 8152855634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-114596 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036114596 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036114596 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036114596 | 05 | IL | MEDICAID | 553180 | 01 | IL | MEDICARE GROUP | OTHER | 834340 | 01 | IL | MEDICARE GROUP # | OTHER | F400220687 | 01 | IL | MEDICARE PTAN | OTHER |