Provider Demographics
NPI:1194793471
Name:LIN, JACK CHI (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:CHI
Last Name:LIN
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 1:1 TAMPA GENERAL CIR
Mailing Address - Street 2:SUITE A327
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3571
Mailing Address - Country:US
Mailing Address - Phone:813-844-4434
Mailing Address - Fax:813-844-4972
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:847-742-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218742207L00000X
VA0101242067207L00000X
IL036-158862207L00000X
FLME124687207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194793471Medicaid
DC022709F89OtherMEDICARE
VA014460F81Medicare PIN
VAI58400Medicare UPIN