=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336536648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHITRA DESAI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BELOIT CLINIC 1905 E. HUEBBE PARKWAY
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-364-2220
-----------------------------------------------------
Fax | 608-363-7368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BELOIT HEALTH SYSTEM INC 1905 E. HUEBBE PARKWAY
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-364-2293
-----------------------------------------------------
Fax | 608-364-5452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | BP10053052
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 69451-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------