Provider Demographics
NPI:1477502326
Name:MODI, KETKI (DO)
Entity Type:Individual
Prefix:DR
First Name:KETKI
Middle Name:
Last Name:MODI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KETKI
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5145 N CALIFORNIA AVE
Mailing Address - Street 2:SCH DEPT OF REHAB SERVICES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3661
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-907-3032
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:SCH DEPT OF REHAB SERVICES
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:773-907-3032
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096575208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG61934Medicare UPIN