Basic Information
| Provider Information | |||||||||
| NPI: | 1538553177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3231 EUCLID AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087837138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3231 EUCLID AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087837138 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2015 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2019-02661 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.