Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086X0206X | Surgical Oncologist | IL |
NPI | 1417973116 |
---|---|
Provider Name | Jeffrey Wayne |
First Address | Chicago, IL 60611-4546 |
Second Address | Chicago, IL 60611-4546 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 12/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G97518 | (02) |