Provider Demographics
NPI:1275862351
Name:TANEJA, KANNAN PARIKH (RPA - C)
Entity Type:Individual
Prefix:MRS
First Name:KANNAN
Middle Name:PARIKH
Last Name:TANEJA
Suffix:
Gender:F
Credentials:RPA - C
Other - Prefix:MS
Other - First Name:KANNAN
Other - Middle Name:SURESH
Other - Last Name:PARIKH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-563-4176
Mailing Address - Fax:312-563-3945
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-563-4176
Practice Address - Fax:312-563-3945
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA872809814A-HMedicare PIN
GA202I970574Medicaid