Provider Demographics
NPI:1427324425
Name:WABICH, JAMIE BRENNA (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:BRENNA
Last Name:WABICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:BRENNA
Other - Last Name:SODIKOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 N WESTMORELAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1671
Mailing Address - Country:US
Mailing Address - Phone:847-535-6083
Mailing Address - Fax:
Practice Address - Street 1:800 N WESTMORELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1671
Practice Address - Country:US
Practice Address - Phone:847-535-6083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-24
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138232207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138232OtherILLINOIS PERMANENT LICENSE