Provider Demographics
NPI:1326187295
Name:GARDEN, JEROME MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MARK
Last Name:GARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E HURON ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2949
Mailing Address - Country:US
Mailing Address - Phone:312-280-0890
Mailing Address - Fax:312-280-9615
Practice Address - Street 1:150 E HURON ST STE 1200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2949
Practice Address - Country:US
Practice Address - Phone:312-280-0890
Practice Address - Fax:312-280-9615
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-063335207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD-89301Medicare UPIN
IL688790Medicare ID - Type Unspecified