Provider Demographics
NPI:1275228439
Name:MODI, VAISHNAVI KALPESH
Entity Type:Individual
Prefix:
First Name:VAISHNAVI
Middle Name:KALPESH
Last Name:MODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOYOLA MEDICINE MACNEAL HOSPITAL 3429 S. OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-783-3347
Mailing Address - Fax:
Practice Address - Street 1:MACNEAL CENTER FOR INTERNAL MEDICINE 3722 S. HARLEM AVE
Practice Address - Street 2:SUITE LL34
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546
Practice Address - Country:US
Practice Address - Phone:708-783-6566
Practice Address - Fax:708-783-6567
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.082523207R00000X
390200000X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program