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General NPI Number Information
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NPI Number | 1467687806
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Entity Type | Organization
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Legal Business Name | ELITE SPORTS MEDICINE INSTITUTE, LTD.
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Dates
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Enumeration Date | 05/28/2009
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Last Update Date | 01/13/2015
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Provider Practice Location Address
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Address Line | 760 PASQUINELLI DR SUITE 304
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City | WESTMONT
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State | IL
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Zip | 60559-5564
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Country | US
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Telephone | 630-789-3764
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Fax | 630-794-9998
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Provider Business Mailing Address
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Address Line | PO BOX 3231
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City | OAK BROOK
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State | IL
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Zip | 60522-3231
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Country | US
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Telephone | 630-789-3764
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Fax | 630-794-9998
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Authorized Official
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Title or Position | PRESIDENT
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Name | KETAN RAJENDRA MODY
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Credential | M.D.
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Telephone | 630-789-3764
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 036119306
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License Number State | IL
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