Provider Demographics
NPI:1497214753
Name:JAYAWICKRAMA, SHALINI
Entity Type:Individual
Prefix:
First Name:SHALINI
Middle Name:
Last Name:JAYAWICKRAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3055
Mailing Address - Country:US
Mailing Address - Phone:312-926-2000
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3055
Practice Address - Country:US
Practice Address - Phone:312-926-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.074887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine