Healthcare Provider Details

I. General information

NPI: 1548250384
Provider Name (Legal Business Name): HIMADRI MAHESH PATEL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16615 S ROUTE 59
PLAINFIELD IL
60586-2921
US

IV. Provider business mailing address

16615 S ROUTE 59
PLAINFIELD IL
60586-2921
US

V. Phone/Fax

Practice location:
  • Phone: 815-609-6300
  • Fax:
Mailing address:
  • Phone: 815-609-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036096440
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier399980
Identifier TypeOTHER
Identifier State
Identifier IssuerGROUP MEDICAL PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: