Provider Demographics
NPI:1467453761
Name:LIPOFF, JAY I (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:I
Last Name:LIPOFF
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 1:8316 EXPRESS DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5895
Mailing Address - Country:US
Mailing Address - Phone:618-998-8447
Mailing Address - Fax:618-998-9787
Practice Address - Street 1:8316 EXPRESS DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5895
Practice Address - Country:US
Practice Address - Phone:618-998-8447
Practice Address - Fax:618-998-9787
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2009-12-22
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IL036099740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099740IMedicaid
IL563590Medicare ID - Type Unspecified
IL036099740IMedicaid