Provider Demographics
NPI:1942241120
Name:PATEL, GHANSHYAM M (MD)
Entity Type:Individual
Prefix:
First Name:GHANSHYAM
Middle Name:M
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1748
Mailing Address - Country:US
Mailing Address - Phone:708-756-0100
Mailing Address - Fax:708-709-6353
Practice Address - Street 1:333 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1748
Practice Address - Country:US
Practice Address - Phone:708-756-0100
Practice Address - Fax:708-709-6353
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069206207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15634Medicare UPIN
ILK17284Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 15
ILK17283Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 16