Provider Demographics
NPI:1528406014
Name:BLACKALLER, JORGE G (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:G
Last Name:BLACKALLER
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 1:102 LAWTON RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2333
Mailing Address - Country:US
Mailing Address - Phone:708-447-8425
Mailing Address - Fax:
Practice Address - Street 1:102 LAWTON RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2333
Practice Address - Country:US
Practice Address - Phone:708-447-8425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.007971207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine