MEDICARE: RIVERGLEN EAR, NOSE & THROAT AND AUDIOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician		IL

General Provider Information

NPI Number	:	1376640730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERGLEN EAR, NOSE & THROAT AND AUDIOLOGY, LLC

Provider Business Mailing Address
First Line	:	11000 E. RT 34
Second Line	:	STE 3
City	:	PLANO
State	:	IL
Zip	:	60545
Country	:	US
Telephone Number	:	630-552-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	11000 E. RT 34
Second Line	:	STE 3
City	:	PLANO
State	:	IL
Zip	:	60545
Country	:	US
Telephone Number	:	630-552-8502
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SANJIV UPADHYAY
Credential	:	M.D.
Telephone Number	:	630-552-8502

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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