Provider Demographics
NPI:1649278185
Name:PATEL, KANUBHAI M (MD)
Entity type:Individual
Prefix:DR
First Name:KANUBHAI
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 1:3165 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5012
Mailing Address - Country:US
Mailing Address - Phone:618-877-3066
Mailing Address - Fax:618-877-3060
Practice Address - Street 1:3165 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5012
Practice Address - Country:US
Practice Address - Phone:618-877-3066
Practice Address - Fax:618-877-3060
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-048978207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048978Medicaid
MO201849601Medicaid
MO000007149Medicare PIN
IL036048978Medicaid
MO201849601Medicaid
ILL17955Medicare PIN