Provider Demographics
NPI:1467687806
Name:ELITE SPORTS MEDICINE INSTITUTE, LTD.
Entity Type:Organization
Organization Name:ELITE SPORTS MEDICINE INSTITUTE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:RAJENDRA
Authorized Official - Last Name:MODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-789-3764
Mailing Address - Street 1:PO BOX 3231
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3231
Mailing Address - Country:US
Mailing Address - Phone:630-789-3764
Mailing Address - Fax:630-794-9998
Practice Address - Street 1:760 PASQUINELLI DR
Practice Address - Street 2:SUITE 304
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5564
Practice Address - Country:US
Practice Address - Phone:630-789-3764
Practice Address - Fax:630-794-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119306207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2367Medicare PIN