Provider Demographics
NPI:1851346134
Name:PANCHAL, PRERANA
Entity Type:Individual
Prefix:
First Name:PRERANA
Middle Name:
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BIESTERFIELD RD
Mailing Address - Street 2:#207
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD
Practice Address - Street 2:#207
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3392
Practice Address - Country:US
Practice Address - Phone:847-545-9028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079396207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079396Medicaid
L82090Medicare ID - Type Unspecified
IL036079396Medicaid
L82086Medicare ID - Type Unspecified
L82091Medicare ID - Type Unspecified