Provider Demographics
NPI:1104866805
Name:ECANOW, JACOB SETH (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SETH
Last Name:ECANOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2475
Mailing Address - Fax:847-570-2942
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-2475
Practice Address - Fax:847-570-2942
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360956362085R0202X
IL2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095636Medicaid
ILL84011Medicare ID - Type Unspecified
ILK07630Medicare ID - Type Unspecified