Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208G00000X | Cardiothoracic Vascular Surgeon | 01026803A | IN |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 036.049922 | IL |
NPI | 1043582158 |
---|---|
Provider Name | Dr. Joel Roy Guillory JR. |
First Address | Oak Lawn, IL 60453-2654 |
Second Address | Oak Lawn, IL 60453-2654 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2012 |
Last Update Date | 04/02/2012 |