Provider Demographics
NPI:1174624415
Name:STEPHEN, JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:STEPHEN
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 1:5 KISH HOSPITAL DR STE 103
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9602
Mailing Address - Country:US
Mailing Address - Phone:630-232-0280
Mailing Address - Fax:630-232-3895
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:630-232-0280
Practice Address - Fax:630-232-3895
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.083380207RC0000X
IL036133593207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE GROUP PTAN
ILF40332641OtherMEDICARE INDIVID PTAN