Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | 016005105 | IL |
NPI | 1003923764 |
---|---|
Provider Name | Dr. Tae-Jun Ahn |
First Address | River Forest, IL 60305-1220 |
Second Address | River Forest, IL 60305-1220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2006 |
Last Update Date | 17/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
016005105 | (05) | IL |
P00631105 | MEDICARE RAILROAD (01) | IL |
U94591 | (02) | IL |