Healthcare Provider Details

I. General information

NPI: 1235661356
Provider Name (Legal Business Name): MONTOO G. PATEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1290
US

IV. Provider business mailing address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-3936
  • Fax: 708-923-8848
Mailing address:
  • Phone: 708-923-3936
  • Fax: 708-923-8848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209017631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: