Provider Demographics
NPI:1215996301
Name:JAIN, PANKAJ (MD)
Entity type:Individual
Prefix:
First Name:PANKAJ
Middle Name:
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-8319
Practice Address - Street 1:3800 W 203RD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1184
Practice Address - Country:US
Practice Address - Phone:708-679-2660
Practice Address - Fax:708-503-3861
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY39423207RP1001X
IL036121222207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00723355OtherRAIL ROAD MEDICARE
IL05-0540914OtherTAX ID
KY000000365405OtherBLUE CROSS BLUE SHIELD
KY64100852Medicaid
IL036121222Medicaid
KYP00256659OtherRAILROAD MEDICARE
KY611308998OtherTAX ID NUMBER
KY000000365405OtherBLUE CROSS BLUE SHIELD
ILP00723355OtherRAIL ROAD MEDICARE
KY64100852Medicaid