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General NPI Number Information
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NPI Number | 1417100157
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Entity Type | Organization
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Legal Business Name | WISE HEALTH PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 10/28/2008
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Last Update Date | 11/12/2009
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Provider Practice Location Address
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Address Line | 4755 N KENMORE AVE
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City | CHICAGO
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State | IL
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Zip | 60640-5015
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Country | US
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Telephone | 773-989-9868
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 WYNNCREST DR
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City | LONG GROVE
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State | IL
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Zip | 60047-5033
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Country | US
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Telephone | 847-322-9602
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | DR. SHEPHALI PATEL
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Credential | MD
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Telephone | 847-322-9602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036091776
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License Number State | IL
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