Healthcare Provider Details

I. General information

NPI: 1104069608
Provider Name (Legal Business Name): RUPA KRISHNASWAMY PATIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CENTRAL ST STE 730
EVANSTON IL
60201
US

IV. Provider business mailing address

1000 CENTRAL ST STE 730
EVANSTON IL
60201-1779
US

V. Phone/Fax

Practice location:
  • Phone: 847-864-3278
  • Fax: 847-676-1727
Mailing address:
  • Phone: 847-864-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0074916
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: