Provider Demographics
NPI:1639117856
Name:HINES, JEROME L (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:HINES
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 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:630-789-3422
Mailing Address - Fax:630-789-9093
Practice Address - Street 1:908 N ELM ST STE 404
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3638
Practice Address - Country:US
Practice Address - Phone:630-789-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068936207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4174006OtherMEDICARE-LOCALITY 16
IL1912218850OtherNPI GROUP PRACTICE
ILIL4177006OtherMEDICARE-LOCALITY 15
IL1912218850OtherNPI GROUP PRACTICE