Provider Demographics
NPI:1649361791
Name:PAHWA, PREM NATH (MD)
Entity type:Individual
Prefix:DR
First Name:PREM
Middle Name:NATH
Last Name:PAHWA
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 1:1431 N WESTERN AVE
Mailing Address - Street 2:134
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:773-685-3846
Mailing Address - Fax:773-685-7264
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:134
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-685-3846
Practice Address - Fax:773-685-7264
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07282Medicaid
ILC41953Medicare UPIN