Provider Demographics
NPI:1437357480
Name:JACK C LEONG MD SC
Entity Type:Organization
Organization Name:JACK C LEONG MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-282-3115
Mailing Address - Street 1:3000 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-5106
Mailing Address - Country:US
Mailing Address - Phone:773-282-3115
Mailing Address - Fax:773-282-0590
Practice Address - Street 1:3000 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-5106
Practice Address - Country:US
Practice Address - Phone:773-282-3115
Practice Address - Fax:773-282-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070436261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44411Medicare PIN