Provider Demographics
NPI:1154307213
Name:MORGAN, JACK (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:MORGAN
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 1:9669 N KENTON
Mailing Address - Street 2:STE 404
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-679-9100
Mailing Address - Fax:847-679-6343
Practice Address - Street 1:9669 N KENTON
Practice Address - Street 2:STE 404
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-679-9100
Practice Address - Fax:847-679-6343
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21605186OtherBCBS
IL036048974Medicaid
IL21605186OtherBCBS
IL036048974Medicaid