Healthcare Provider Details

I. General information

NPI: 1326487232
Provider Name (Legal Business Name): SHRUTI JAGANNATH PATIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62702-3757
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-0182
  • Fax: 217-545-4735
Mailing address:
  • Phone: 217-545-0182
  • Fax: 217-545-4735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036146897
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125063259
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036146897
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: