Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036.148437 | IL |
N | 207QS0010X | Family Doctor - Sports Medicine | 036148437 | IL |
NPI | 1285097113 |
---|---|
Provider Name | Jeevan Abraham |
First Address | Gurnee, IL 60031-1651 |
Second Address | Gurnee, IL 60031-1651 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2016 |
Last Update Date | 30/06/2021 |