Provider Demographics
NPI:1639122583
Name:ANTONY, JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:ANTONY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEROME
Other - Middle Name:
Other - Last Name:ANTONY
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:327 W 76TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-1604
Mailing Address - Country:US
Mailing Address - Phone:773-224-6837
Mailing Address - Fax:773-224-6841
Practice Address - Street 1:327 W 76TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-1604
Practice Address - Country:US
Practice Address - Phone:773-224-6837
Practice Address - Fax:773-224-6841
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062248Medicaid
ILD14706Medicare UPIN
IL036062248Medicaid