Healthcare Provider Details

I. General information

NPI: 1437991080
Provider Name (Legal Business Name): MIDHUN AJIKUMAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

311 S WACKER DR STE 1460
CHICAGO IL
60606-6623
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: