Basic Information
| Provider Information | |||||||||
| NPI: | 1841279981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LERMA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | EDGAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DESPLAINES ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606615500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 3126549930 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 W. 95TH ST | ||||||||
| Address2: | MARY POTTER BLDG ST. 11 | ||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084992243 | ||||||||
| FaxNumber: | 7084241799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036097893 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036097893 | 05 | IL | MEDICAID |