Provider Demographics
NPI:1629334743
Name:HARSHAD M. MEHTA MD SC
Entity Type:Organization
Organization Name:HARSHAD M. MEHTA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARSHAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-425-8900
Mailing Address - Street 1:2850 W. 95TH STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805
Mailing Address - Country:US
Mailing Address - Phone:708-425-8900
Mailing Address - Fax:708-425-9612
Practice Address - Street 1:2850 W. 95TH STREET
Practice Address - Street 2:SUITE 206
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:708-425-8900
Practice Address - Fax:708-425-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-517162084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051716Medicaid
IL482300Medicare PIN