Provider Demographics
NPI:1356641120
Name:NITTOR R. JAYARAM MD LTD
Entity Type:Organization
Organization Name:NITTOR R. JAYARAM MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NITTOR
Authorized Official - Middle Name:R
Authorized Official - Last Name:JAYARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-532-4200
Mailing Address - Street 1:17031 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2739
Mailing Address - Country:US
Mailing Address - Phone:708-532-4200
Mailing Address - Fax:708-532-9465
Practice Address - Street 1:17031 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2739
Practice Address - Country:US
Practice Address - Phone:708-532-4200
Practice Address - Fax:708-532-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056518207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360565918Medicaid
IL633900Medicare PIN
IL0360565918Medicaid