Provider Demographics
NPI:1497854038
Name:BOLANO, JAIME O (MD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:O
Last Name:BOLANO
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 1:2209 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3916
Mailing Address - Country:US
Mailing Address - Phone:773-847-1199
Mailing Address - Fax:
Practice Address - Street 1:2209 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3916
Practice Address - Country:US
Practice Address - Phone:773-847-1199
Practice Address - Fax:773-847-6592
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061720Medicaid
IL31620158OtherBLUE SHIELD
IL036061720Medicaid
D14834Medicare UPIN