Provider Demographics
NPI:1730616251
Name:SILBERG, JORDAN S L
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:S L
Last Name:SILBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E ILLINOIS ST APT 2907
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6304
Mailing Address - Country:US
Mailing Address - Phone:484-553-4696
Mailing Address - Fax:
Practice Address - Street 1:1 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8901
Practice Address - Country:US
Practice Address - Phone:484-553-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.151817208000000X
390200000X
CT71212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program