Provider Demographics
NPI:1669480844
Name:SWALE, JEROME A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:A
Last Name:SWALE
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 1:352 BROWN BLVD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2458
Mailing Address - Country:US
Mailing Address - Phone:815-932-2020
Mailing Address - Fax:815-937-0060
Practice Address - Street 1:352 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2458
Practice Address - Country:US
Practice Address - Phone:815-932-2020
Practice Address - Fax:815-937-0060
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082000Medicaid
ILE84590Medicare UPIN
CD6154Medicare PIN
957330Medicare PIN
IL957330Medicare ID - Type Unspecified