Healthcare Provider Details

I. General information

NPI: 1356567978
Provider Name (Legal Business Name): MAHENDRAGOUDA PATIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6302
US

IV. Provider business mailing address

1225 S PLYMOUTH CT
CHICAGO IL
60605-2719
US

V. Phone/Fax

Practice location:
  • Phone: 708-597-2173
  • Fax: 708-597-2315
Mailing address:
  • Phone: 708-597-2173
  • Fax: 708-597-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: