Healthcare Provider Details

I. General information

NPI: 1891986907
Provider Name (Legal Business Name): SUBHASH J PATEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST STE 320
PEORIA IL
61602-1005
US

IV. Provider business mailing address

900 MAIN ST STE 320
PEORIA IL
61602-1005
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-3140
  • Fax: 309-672-3145
Mailing address:
  • Phone: 309-672-3140
  • Fax: 309-672-3145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-072639
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036-072639
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: