Basic Information
| Provider Information | |||||||||
| NPI: | 1396074753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SA PADUA MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9201 CALUMET AVE | ||||||||
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| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198369024 | ||||||||
| FaxNumber: | 2198360034 | ||||||||
| Practice Location | |||||||||
| Address1: | 2310 YORK ST | ||||||||
| Address2: | SUITE 2C | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083884902 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 08/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | JABBOUR | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2198369024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036119492 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.