Healthcare Provider Details

I. General information

NPI: 1154701076
Provider Name (Legal Business Name): HEATHER MECHELLE CLOUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRA DIVYESHBHAI KAKADIA

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 RYAN PKWY
ALGONQUIN IL
60102-4530
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-9555
  • Fax: 847-658-2167
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036173797
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73987-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: