Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 036104913 | IL |
NPI | 1366476947 |
---|---|
Provider Name | Jonathan S Bailey |
First Address | Urbana, IL 61801-2500 |
Second Address | Urbana, IL 61801-2500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 26/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H58213 | (02) | |
H58213 | (02) | IL |