Provider Demographics
NPI:1164492922
Name:LEVINE, JACK M (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:LEVINE
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 1:7428 STATE ROUTE 772
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9602
Mailing Address - Country:US
Mailing Address - Phone:740-493-1979
Mailing Address - Fax:
Practice Address - Street 1:7428 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9602
Practice Address - Country:US
Practice Address - Phone:740-493-1979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105772207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC35094Medicare UPIN