Provider Demographics
NPI:1841298833
Name:AHN, JIYONG (MD)
Entity type:Individual
Prefix:
First Name:JIYONG
Middle Name:
Last Name:AHN
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 1:2001 BUTTERFIELD ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1069
Mailing Address - Country:US
Mailing Address - Phone:630-725-2730
Mailing Address - Fax:844-205-5691
Practice Address - Street 1:358 UNIVERSAL DR N
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3163
Practice Address - Country:US
Practice Address - Phone:475-655-3970
Practice Address - Fax:475-655-3971
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1871932085R0202X
CT441962085R0204X
PAMD454162085R0204X
VA01012576912085R0204X
MDD795322085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2323842OtherMEDICARE GROUP PTAN
VAC10441OtherMEDICARE GROUP PTAN
IL789510OtherGROUP MEDICARE PTAN
IL789511OtherGROUP MEDICARE PTAN
CTD100037356OtherGROUP MEDICARE PTAN
VAG01618OtherGROUP MEDICARE PTAN
PA194873OtherGROUP MEDICARE PTAN
MD339LOtherMEDICARE GROUP PTAN
CTD100037356OtherGROUP MEDICARE PTAN
G46698Medicare UPIN
VA419367YAY8Medicare PIN
MD437978YA20Medicare PIN
NCNCO337AMedicare PIN
IL789511OtherGROUP MEDICARE PTAN
ILF400238752Medicare PIN
CTD400206800Medicare PIN
IL789510OtherGROUP MEDICARE PTAN