Provider Demographics
NPI:1548202716
Name:COWAN, JEREMY (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:COWAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 S GREENWOOD AVE
Mailing Address - Street 2:#108
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-7051
Mailing Address - Country:US
Mailing Address - Phone:773-978-3338
Mailing Address - Fax:773-978-4606
Practice Address - Street 1:8751 S GREENWOOD AVE
Practice Address - Street 2:#108
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-7051
Practice Address - Country:US
Practice Address - Phone:773-978-3338
Practice Address - Fax:773-978-4606
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004924213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633823OtherBCBS
P00072953OtherRAILROAD MEDICARE NUMBER
IL601015700OtherDEPT OF LABOR
ILIL5392001Medicare PIN
IL601015700OtherDEPT OF LABOR
ILK03510Medicare PIN