Basic Information
| Provider Information | |||||||||
| NPI: | 1720132210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JWEIED | ||||||||
| FirstName: | EIAS | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 BORMET DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464044 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 95TH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 0834632877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 56018-20 | WI | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 01067276A | IN | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 036-100901 | IL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1720132210 | 05 | MI | MEDICAID | 200992020D | 05 | IN | MEDICAID | 200992020B | 05 | IN | MEDICAID | 200992020E | 05 | IN | MEDICAID | 036100901 | 05 | IL | MEDICAID | 200992020C | 05 | IN | MEDICAID | 200992020A | 05 | IN | MEDICAID |