Basic Information
| Provider Information | |||||||||
| NPI: | 1063592095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | SHEPHALI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WYNNCREST DR | ||||||||
| Address2: | |||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739899868 | ||||||||
| FaxNumber: | 7739899824 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739899868 | ||||||||
| FaxNumber: | 7739899824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036091776 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036091776 | 05 | IL | MEDICAID |