Basic Information
| Provider Information | |||||||||
| NPI: | 1649248204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTMAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855552 | ||||||||
| FaxNumber: | 8152855865 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152855552 | ||||||||
| FaxNumber: | 8152855865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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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 | 207P00000X | 036-077540 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036077540 | 05 | IL | MEDICAID | L53041 | 01 | IL | MEDICARE PTAN | OTHER | 800200 | 01 | IL | MEDICARE GROUP PROVIDER NUMBER | OTHER | L10167 | 01 | IL | MEDICARE PTAN | OTHER |