Provider Demographics
NPI:1669697868
Name:JERRY J ITKONEN, SC
Entity type:Organization
Organization Name:JERRY J ITKONEN, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-799-8440
Mailing Address - Street 1:18141 DIXIE HWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2238
Mailing Address - Country:US
Mailing Address - Phone:708-799-8440
Mailing Address - Fax:708-799-8446
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-331-0405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060989207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D13345Medicare UPIN
532500Medicare ID - Type Unspecified