Provider Demographics
NPI:1417074774
Name:PITHADIA, ANISH PRAVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANISH
Middle Name:PRAVIN
Last Name:PITHADIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3633 W LAKE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-5801
Mailing Address - Country:US
Mailing Address - Phone:847-510-2805
Mailing Address - Fax:847-510-2806
Practice Address - Street 1:3633 W LAKE AVE STE 108
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5801
Practice Address - Country:US
Practice Address - Phone:847-510-2805
Practice Address - Fax:847-510-2806
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619414OtherBCBS GRP
IL3633309286030501Medicaid
IL216966014 EP&DP ICCMedicare PIN
IL3633309286030501Medicaid