Provider Demographics
NPI:1639412943
Name:CHOUGHALE, IMTIAZ (RN)
Entity Type:Individual
Prefix:MR
First Name:IMTIAZ
Middle Name:
Last Name:CHOUGHALE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18025 SAYRE AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3955
Mailing Address - Country:US
Mailing Address - Phone:708-444-7849
Mailing Address - Fax:
Practice Address - Street 1:18025 SAYRE AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3955
Practice Address - Country:US
Practice Address - Phone:708-444-7849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.263993163WC0200X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine