Basic Information
Provider Information | |||||||||
NPI: | 1528054145 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | JON | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1472 SOLUTIONS CTR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606771004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135573333 | ||||||||
FaxNumber: | 5135573332 | ||||||||
Practice Location | |||||||||
Address1: | 100 ARROW SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | OH | ||||||||
PostalCode: | 450367002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132827075 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2005 | ||||||||
LastUpdateDate: | 12/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.089274 | OH | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 200887040 | 05 | IN |   | MEDICAID | 7100041250 | 05 | KY |   | MEDICAID | 2801605 | 05 | OH |   | MEDICAID |