Healthcare Provider Details

I. General information

NPI: 1710728530
Provider Name (Legal Business Name): ANUPAM PATIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 09/03/2026
Certification Date:
Deactivation Date: 01/16/2025
Reactivation Date: 09/03/2026

III. Provider practice location address

545 RIDGE RD
MUNSTER IN
46321
US

IV. Provider business mailing address

545 RIDGE RD
MUNSTER IN
46321
US

V. Phone/Fax

Practice location:
  • Phone: 219-940-5765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901602097
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: