MEDICARE: DR. SUJAL V PANCHAL M.D.

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	208000000X	Pediatrics Physician	036119020	IL
2	208000000X	Pediatrics Physician	A82152	CA
3	208000000X	Pediatrics Physician	4301106399	MI

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629174024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUJAL V PANCHAL M.D.

Provider Business Mailing Address
First Line	:	100 BATSON CT
Second Line	:	SUITE 106
City	:	NEW LENOX
State	:	IL
Zip	:	60451-1564
Country	:	US
Telephone Number	:	815-463-9747
Fax Number	:	815-463-9749

Provider Business Practice Location Address
First Line	:	100 BATSON CT
Second Line	:	SUITE 106
City	:	NEW LENOX
State	:	IL
Zip	:	60451-1564
Country	:	US
Telephone Number	:	815-463-9747
Fax Number	:	815-463-9749

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	10/19/2020

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