Basic Information
| Provider Information | |||||||||
| NPI: | 1376774372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAYLOCK | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUA | ||||||||
| OtherFirstName: | JAIME | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19550 GOVERNORS HWY | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089578750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19550 GOVERNORS HWY | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089578750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036-128942 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036-128942 | 01 | IL | STATE LICENSE NUMBER | OTHER | 125056222 | 01 | IL | STATE LICENSE NUMBER | OTHER |