Provider Demographics
NPI:1134119035
Name:AMIN, NARENDRA J (MD)
Entity Type:Individual
Prefix:
First Name:NARENDRA
Middle Name:J
Last Name:AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0639
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:14552 JOHN HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2640
Practice Address - Country:US
Practice Address - Phone:708-226-6858
Practice Address - Fax:708-460-5381
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-058553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058553Medicaid
IL212537Medicare PIN
ILK22412Medicare PIN
ILP00278529Medicare PIN
IL036058553Medicaid