Basic Information
| Provider Information | |||||||||
| NPI: | 1831152966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAN | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 GRAND AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076316300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015675787 | ||||||||
| FaxNumber: | 2015677652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MA067677 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0003450 | 05 | NJ | MEDICAID |