Basic Information
| Provider Information | |||||||||
| NPI: | 1417183633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 N AIRLITE ST | ||||||||
| Address2: | DEPARTMENT OF PATHOLOGY | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476953200 | ||||||||
| FaxNumber: | 8479315778 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 N AIRLITE ST | ||||||||
| Address2: | DEPARTMENT OF PATHOLOGY | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476953200 | ||||||||
| FaxNumber: | 8479315778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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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 | 207ZP0102X | 036130363 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZB0001X | 036130363 | IL | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine |
ID Information
| ID | Type | State | Issuer | Description | 125056229 | 05 | IL | MEDICAID |