Provider Demographics
NPI:1295197481
Name:TIWARI, KANCHAN (MD)
Entity Type:Individual
Prefix:
First Name:KANCHAN
Middle Name:
Last Name:TIWARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-942-2932
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:150 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1497
Practice Address - Country:US
Practice Address - Phone:815-942-2932
Practice Address - Fax:815-416-6097
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9875207R00000X
IL036152773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036152773OtherLICENSE