Provider Demographics
NPI:1073683439
Name:PALOS MEDICAL CARE SC
Entity Type:Organization
Organization Name:PALOS MEDICAL CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRANAV
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-389-7663
Mailing Address - Street 1:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482
Mailing Address - Country:US
Mailing Address - Phone:708-389-7663
Mailing Address - Fax:708-389-7664
Practice Address - Street 1:12800 S RIDGELAND AVE
Practice Address - Street 2:UNIT D
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-389-7663
Practice Address - Fax:708-389-7664
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALOS MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091090Medicaid
G22238Medicare UPIN
705480Medicare ID - Type Unspecified