Provider Demographics
NPI:1942482278
Name:JESSE K. PARK MD SC
Entity Type:Organization
Organization Name:JESSE K. PARK MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:KITAI
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-325-8681
Mailing Address - Street 1:100 TOWER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5777
Mailing Address - Country:US
Mailing Address - Phone:630-325-8681
Mailing Address - Fax:630-325-3936
Practice Address - Street 1:100 TOWER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-5777
Practice Address - Country:US
Practice Address - Phone:630-325-8681
Practice Address - Fax:630-325-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-080235261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212867Medicare PIN
IL212866Medicare PIN
ILF57281Medicare UPIN
ILK24387Medicare PIN
ILK24386Medicare PIN