Provider Demographics
NPI:1942450366
Name:KANKAKEE INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:KANKAKEE INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-952-1412
Mailing Address - Street 1:7641 NEWFIELD LN
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5539
Mailing Address - Country:US
Mailing Address - Phone:630-952-1412
Mailing Address - Fax:630-952-1447
Practice Address - Street 1:7641 NEWFIELD LN
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-5539
Practice Address - Country:US
Practice Address - Phone:630-952-1412
Practice Address - Fax:630-952-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty