Provider Demographics
NPI:1013448448
Name:JACK C. LEONG MD SC
Entity Type:Organization
Organization Name:JACK C. LEONG MD SC
Other - Org Name:JACK C. LEONG MD SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D, S.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-282-3115
Mailing Address - Street 1:3000 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-5106
Mailing Address - Country:US
Mailing Address - Phone:773-231-2885
Mailing Address - Fax:
Practice Address - Street 1:3000 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-5106
Practice Address - Country:US
Practice Address - Phone:773-231-2885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CICERO PROMPT CARE AND FAMILY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-27
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070436207K00000X, 207Q00000X
IL336034323261QP2300X, 302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070436Medicaid
IL036070436Medicaid
IL793120Medicare PIN