Provider Demographics
NPI:1215980321
Name:CHAMBERLIN, JACK R (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:CHAMBERLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:847-981-3680
Mailing Address - Fax:847-956-5122
Practice Address - Street 1:800 BIESTERFIELD RD STE G01
Practice Address - Street 2:WIMMER BUILDING
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:847-956-5122
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036086925207RC0000X
IL036-086925207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6305015OtherMEDICARE PTAN LOC 15
IL1720371669OtherNPI GROUP PRACTICE
ILIL6304015OtherMEDICARE PTAN LOC 16
ILP01008734OtherRRMC PTAN
ILIL6304015OtherMEDICARE PTAN LOC 16