Healthcare Provider Details

I. General information

NPI: 1851753636
Provider Name (Legal Business Name): PALLAN PRIMARY CARE LTD S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W 22ND ST STE 211
OAK BROOK IL
60523
US

IV. Provider business mailing address

PO BOX 428
DOWNERS GROVE IL
60515-0428
US

V. Phone/Fax

Practice location:
  • Phone: 630-368-3909
  • Fax:
Mailing address:
  • Phone: 630-368-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-137215
License Number StateIL

VIII. Authorized Official

Name: TONY VARGHESE PALLAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 913-980-9289