Basic Information
| Provider Information | |||||||||
| NPI: | 1003841651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHATAK | ||||||||
| FirstName: | MOHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474129213 | ||||||||
| FaxNumber: | 8474129381 | ||||||||
| Practice Location | |||||||||
| Address1: | 7435 W TALCOTT AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737925138 | ||||||||
| FaxNumber: | 7737925124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 0001619902 | 01 | IL | BLUE CROSS BLUE SHIELD-IL | OTHER | 036053629-1 | 05 | IL | MEDICAID |