Healthcare Provider Details

I. General information

NPI: 1174696884
Provider Name (Legal Business Name): DR. PARITOSH TIWARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HERITAGE DR
BOURBONNAIS IL
60914-2701
US

IV. Provider business mailing address

20 HERITAGE DR
BOURBONNAIS IL
60914-2701
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-4880
  • Fax: 815-936-5173
Mailing address:
  • Phone: 815-937-4880
  • Fax: 815-936-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number363094959
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: