Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 125.076883 | IL |
NPI | 1003430208 |
---|---|
Provider Name | Dr. Jared Kealy |
First Address | Chicago, IL 60622-2743 |
Second Address | Chicago, IL 60622-2743 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2020 |
Last Update Date | 04/06/2020 |