Provider Demographics
NPI:1003846908
Name:KAIROUZ, JEANNE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:MARIE
Last Name:KAIROUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3800
Mailing Address - Country:US
Mailing Address - Phone:217-422-6100
Mailing Address - Fax:
Practice Address - Street 1:1770 E LAKE SHORE DR STE 105
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3800
Practice Address - Country:US
Practice Address - Phone:217-422-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245153207RC0000X
IL036128746207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003846908OtherVA MEDICAID
IL036128746Medicaid
DC013824ZC3UMedicare PIN
VA1003846908OtherVA MEDICAID