Provider Demographics
NPI:1770687279
Name:BOURAND, JEAN E (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:E
Last Name:BOURAND
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 1:5025 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639
Mailing Address - Country:US
Mailing Address - Phone:773-622-6955
Mailing Address - Fax:773-622-6989
Practice Address - Street 1:5025 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639
Practice Address - Country:US
Practice Address - Phone:773-622-6955
Practice Address - Fax:773-622-6989
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36065922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31600851OtherBCBS
31600851OtherBCBS
722550Medicare ID - Type Unspecified