Healthcare Provider Details

I. General information

NPI: 1376640730
Provider Name (Legal Business Name): RIVERGLEN EAR, NOSE & THROAT AND AUDIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 E. RT 34 STE 3
PLANO IL
60545
US

IV. Provider business mailing address

11000 E. RT 34 STE 3
PLANO IL
60545
US

V. Phone/Fax

Practice location:
  • Phone: 630-552-8502
  • Fax:
Mailing address:
  • Phone: 630-552-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: SANJIV UPADHYAY
Title or Position: OWNER
Credential: M.D.
Phone: 630-552-8502