Provider Demographics
NPI:1922115377
Name:JEAN L. WALSH FAMILY PRACTITIONER, LTD.
Entity Type:Organization
Organization Name:JEAN L. WALSH FAMILY PRACTITIONER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-838-2888
Mailing Address - Street 1:16151 WEBER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-0863
Mailing Address - Country:US
Mailing Address - Phone:815-838-2888
Mailing Address - Fax:815-838-0222
Practice Address - Street 1:16151 WEBER ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0863
Practice Address - Country:US
Practice Address - Phone:815-838-2888
Practice Address - Fax:815-838-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-089648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02226675OtherBLUE CROSS BLUE SHIELD
IL591570Medicare ID - Type Unspecified
IL02226675OtherBLUE CROSS BLUE SHIELD