Healthcare Provider Details

I. General information

NPI: 1619434602
Provider Name (Legal Business Name): ROSHNI K PATEL PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1865
  • Fax: 737-702-6809
Mailing address:
  • Phone: 773-702-1865
  • Fax: 773-702-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112021
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: