Provider Demographics
NPI:1487673448
Name:LEVINE, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LEVINE
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 1:40 VALLEY STREAM PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:
Practice Address - Street 1:700 PASQUINELLI DR
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1382
Practice Address - Country:US
Practice Address - Phone:630-323-8690
Practice Address - Fax:630-323-8657
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361007922085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0221524519OtherBLUE CROSS BLUE SHIELD
IL036100792Medicaid
0221524519OtherBLUE CROSS BLUE SHIELD
300129599Medicare PIN
H17182Medicare UPIN
IL036100792Medicaid