Provider Demographics
NPI:1114326956
Name:KETAN R PATEL
Entity Type:Organization
Organization Name:KETAN R PATEL
Other - Org Name:KETAN R PATEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SELF EMPLOYED
Authorized Official - Prefix:DR
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-872-1221
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-872-1221
Mailing Address - Fax:815-872-2304
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-872-1221
Practice Address - Fax:815-872-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083069Medicaid
IL1114910528OtherNPI
IL973630Medicare PIN