Provider Demographics
NPI:1518115948
Name:BOUGHANEM, JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:BOUGHANEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAMAL
Other - Middle Name:
Other - Last Name:BOUGHANEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2718 N WILTON AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2875
Mailing Address - Country:US
Mailing Address - Phone:312-371-1861
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST FL 13
Practice Address - Street 2:DEPARTMENT OF ORTHOPAEDIC SURGERY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3060
Practice Address - Country:US
Practice Address - Phone:312-926-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73259-20207X00000X
IL036120773207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518115948Medicaid