Provider Demographics
NPI:1184695520
Name:WALL, JARROD C (MD)
Entity type:Individual
Prefix:
First Name:JARROD
Middle Name:C
Last Name:WALL
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:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:747 N RUTLEDGE ST FL 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7795
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46894208600000X
IL036.121923208600000X
IL036-1219232086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-121923Medicaid
MN492479700Medicaid
IL036-121923Medicaid
MN492479700Medicaid
I22856Medicare UPIN