Provider Demographics
NPI:1659603868
Name:PINAKINPRASAD DAVE, MD, SC
Entity Type:Organization
Organization Name:PINAKINPRASAD DAVE, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PINAKINPRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-895-6439
Mailing Address - Street 1:1940 E 170TH PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3703
Mailing Address - Country:US
Mailing Address - Phone:708-895-6439
Mailing Address - Fax:
Practice Address - Street 1:1851 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2252
Practice Address - Country:US
Practice Address - Phone:708-868-2300
Practice Address - Fax:708-868-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055316Medicaid
IL552820Medicare PIN
ILD14224Medicare UPIN