Provider Demographics
NPI:1144476938
Name:MORENO, JAIME (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:708-783-7070
Mailing Address - Fax:
Practice Address - Street 1:3249 S. OAK PARK AVE.
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-783-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125432207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine