Healthcare Provider Details

I. General information

NPI: 1346245321
Provider Name (Legal Business Name): SATYA M MISHRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17850 KEDZIE AVE STE 3500
HAZEL CREST IL
60429-2082
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-957-4011
  • Fax: 708-957-4013
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036-106636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: