Healthcare Provider Details

I. General information

NPI: 1295175487
Provider Name (Legal Business Name): PRAYAG NAINESHKUMAR PATEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E GRANT ST
MACOMB IL
61455-3313
US

IV. Provider business mailing address

525 E GRANT ST
MACOMB IL
61455-3313
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-4101
  • Fax:
Mailing address:
  • Phone: 309-833-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number336100624
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: