Provider Demographics
NPI:1891883773
Name:DALY, JEROME T (DO)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:T
Last Name:DALY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:STE 265
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9623
Mailing Address - Country:US
Mailing Address - Phone:815-727-4292
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD STE 265
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9623
Practice Address - Country:US
Practice Address - Phone:815-469-8806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057011207QG0300X
IL036057011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14006Medicare UPIN
ILL97702Medicare ID - Type Unspecified