Provider Demographics
NPI:1134212665
Name:KANKAKEE VALLEY OB/GYN,LLC
Entity type:Organization
Organization Name:KANKAKEE VALLEY OB/GYN,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAPAN
Authorized Official - Middle Name:ASHVIN
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-933-4510
Mailing Address - Street 1:375 N WALL STREET
Mailing Address - Street 2:SUITE P630
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-933-4510
Mailing Address - Fax:815-933-4259
Practice Address - Street 1:375 N WALL STREET
Practice Address - Street 2:SUITE P630
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-933-4510
Practice Address - Fax:815-933-4259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL173000000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
04628061OtherBC/BS PROVIDER #
ILH07401Medicare UPIN
ILI07057Medicare UPIN
IL902690Medicare ID - Type Unspecified