Provider Demographics
NPI:1639568447
Name:LAI, JEREMY (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LAI
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 1:0S036 CHURCH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1203
Mailing Address - Country:US
Mailing Address - Phone:331-732-4600
Mailing Address - Fax:331-732-4602
Practice Address - Street 1:0S036 CHURCH ST STE 300
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1203
Practice Address - Country:US
Practice Address - Phone:331-732-4600
Practice Address - Fax:331-732-4602
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069916208800000X
IL036165596208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology