1407095821 NPI number — PITRODA MEDICAL LLC

Table of content: (NPI 1407095821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407095821 NPI number — PITRODA MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PITRODA MEDICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407095821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 967
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-0967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-532-6029
Provider Business Mailing Address Fax Number:
708-532-6095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 W HIGGINS RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
HOFFMAN ESTATES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60169-2428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-755-8619
Provider Business Practice Location Address Fax Number:
847-278-5398
Provider Enumeration Date:
02/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PITRODA
Authorized Official First Name:
PAROL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN / OWNER
Authorized Official Telephone Number:
248-935-6690

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036115162 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036115162 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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