Basic Information
| Provider Information | |||||||||
| NPI: | 1487987814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SERAG | ||||||||
| FirstName: | JOHANN SEBASTIAN JC | ||||||||
| MiddleName: | REYES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3603 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605223603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737727858 | ||||||||
| FaxNumber: | 7732766668 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 DIVISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606222853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735238600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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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 | MD446474 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-141804 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12464493 | 01 | IL | CAQH | OTHER | 036141804 | 05 | IL | MEDICAID |