=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174696884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. PARITOSH TIWARI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 HERITAGE DR
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-937-4880
-----------------------------------------------------
Fax | 815-936-5173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 HERITAGE DR
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-937-4880
-----------------------------------------------------
Fax | 815-936-5173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 363094959
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------