Healthcare Provider Details

I. General information

NPI: 1730110156
Provider Name (Legal Business Name): SHOBHANA PATODIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR STREET SUITE 206
MELROSE PARK IL
60160
US

IV. Provider business mailing address

1111 SUPERIOR ST SUITE 206
MELROSE PARK IL
60160
US

V. Phone/Fax

Practice location:
  • Phone: 708-338-9387
  • Fax:
Mailing address:
  • Phone: 708-338-9397
  • Fax: 708-338-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036054216
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036054216
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: