=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922152370
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANDULAL M PATEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 09/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4074 S ARCHER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-847-1013
-----------------------------------------------------
Fax | 773-847-0265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4074 S ARCHER AVENUE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-847-1013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 03648335
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 03648335
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------