Provider Demographics
NPI:1396074753
Name:SA PADUA MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:SA PADUA MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:JABBOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-9024
Mailing Address - Street 1:9201 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2807
Mailing Address - Country:US
Mailing Address - Phone:219-836-9024
Mailing Address - Fax:219-836-0034
Practice Address - Street 1:2310 YORK ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2411
Practice Address - Country:US
Practice Address - Phone:708-388-4902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3468Medicare PIN