Provider Demographics
NPI:1164698536
Name:JACK W. LENOX, LTD
Entity Type:Organization
Organization Name:JACK W. LENOX, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:LENOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-965-6644
Mailing Address - Street 1:1415 E STATE ST STE 800
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2344
Mailing Address - Country:US
Mailing Address - Phone:815-965-6644
Mailing Address - Fax:815-965-8974
Practice Address - Street 1:1415 E STATE ST STE 800
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2344
Practice Address - Country:US
Practice Address - Phone:815-965-6644
Practice Address - Fax:815-965-8974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068164207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068164Medicaid
ILD16044Medicare UPIN
IL036068164Medicaid