Healthcare Provider Details

I. General information

NPI: 1942278973
Provider Name (Legal Business Name): SANJAY K NIGAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 STATE ROUTE 162 STE 201
MARYVILLE IL
62062-8530
US

IV. Provider business mailing address

6805 STATE ROUTE 162 STE 201
MARYVILLE IL
62062-8530
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5019
  • Fax: 618-288-5059
Mailing address:
  • Phone: 618-288-5019
  • Fax: 618-288-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036107024
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: