MEDICARE: KETAN PATEL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036083069	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114910528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETAN PATEL MD

Provider Business Mailing Address
First Line	:	530 PARK AVE E
Second Line	:	STE 101
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-872-1221
Fax Number	:	815-872-2304

Provider Business Practice Location Address
First Line	:	530 PARK AVE E
Second Line	:	STE 101
City	:	PRINCETON
State	:	IL
Zip	:	61356-3901
Country	:	US
Telephone Number	:	815-872-1221
Fax Number	:	815-872-2304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	10/15/2020

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Directions to “ KETAN PATEL MD” Practice Location

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