1629174024 NPI number — DR. SUJAL V PANCHAL M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629174024 NPI number — DR. SUJAL V PANCHAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANCHAL
Provider First Name:
SUJAL
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FADIA
Provider Other First Name:
SUJAL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629174024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BATSON CT
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-463-9747
Provider Business Practice Location Address Fax Number:
815-463-9749
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036119020 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A82152 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 4301106399 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036119020 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSP40248F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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