Provider Demographics
NPI:1417100157
Name:WISE HEALTH PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WISE HEALTH PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEPHALI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-322-9602
Mailing Address - Street 1:2600 WYNNCREST DR
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5033
Mailing Address - Country:US
Mailing Address - Phone:847-322-9602
Mailing Address - Fax:
Practice Address - Street 1:4755 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5015
Practice Address - Country:US
Practice Address - Phone:773-989-9868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360917762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01637603OtherBLUE CROSS/BLUE SHIELD
IL036091776Medicaid
IL212250Medicare Oscar/Certification
ILIL1064Medicare Oscar/Certification