Healthcare Provider Details

I. General information

NPI: 1558583468
Provider Name (Legal Business Name): SAMATA J SHROFF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVENUE
ZION IL
60099
US

IV. Provider business mailing address

2361 PAYSPHERE CIRCLE
CHICAGO IL
60674
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-6259
  • Fax: 847-872-5716
Mailing address:
  • Phone: 847-746-4358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002527
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.002527
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: