=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629334743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARSHAD M. MEHTA MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2012
-----------------------------------------------------
Last Update Date | 04/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2850 W. 95TH STREET SUITE 206
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-425-8900
-----------------------------------------------------
Fax | 708-425-9612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2850 W. 95TH STREET SUITE 206
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-425-8900
-----------------------------------------------------
Fax | 708-425-9612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HARSHAD M. MEHTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-425-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number | 036-51716
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036-51716
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------