Healthcare Provider Details

I. General information

NPI: 1134212665
Provider Name (Legal Business Name): KANKAKEE VALLEY OB/GYN,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N WALL STREET SUITE P630
KANKAKEE IL
60901
US

IV. Provider business mailing address

375 N WALL STREET SUITE P630
KANKAKEE IL
60901
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-4510
  • Fax: 815-933-4259
Mailing address:
  • Phone: 815-933-4510
  • Fax: 815-933-4259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateIL

VIII. Authorized Official

Name: TAPAN ASHVIN MEHTA
Title or Position: OWNER
Credential: M.D.
Phone: 815-933-4510