Provider Demographics
NPI:1669546685
Name:JIN, BAILAN (DN)
Entity type:Individual
Prefix:
First Name:BAILAN
Middle Name:
Last Name:JIN
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 S CHINA PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1536
Mailing Address - Country:US
Mailing Address - Phone:773-386-2683
Mailing Address - Fax:312-225-4047
Practice Address - Street 1:2165 S CHINA PL
Practice Address - Street 2:SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1536
Practice Address - Country:US
Practice Address - Phone:773-386-2683
Practice Address - Fax:312-225-4047
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181-000303174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633495OtherBLUESHIELD PROVIDER NUMBE
IL181-000303OtherLICENSE NUMBER
IL01633495OtherBLUESHIELD PROVIDER NUMBE