Basic Information
| Provider Information | |||||||||
| NPI: | 1366491193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAPAZIAN | ||||||||
| FirstName: | JACQUES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1389 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628640028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182420672 | ||||||||
| FaxNumber: | 6182420862 | ||||||||
| Practice Location | |||||||||
| Address1: | 4117 S WATER TOWER PL | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182420672 | ||||||||
| FaxNumber: | 6182420862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04127654 | 01 | IL | BCBS OF IL PROVIDER ID# | OTHER | 293973 | 01 | IL | HEALTHLINK PROVIDER ID# | OTHER | 027794 | 01 | IL | HEALTH ALLIANCE ID# | OTHER | 55563 | 01 | IL | GHP PROVIDER ID# | OTHER |