Basic Information
| Provider Information | |||||||||
| NPI: | 1750739900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAMNANI | ||||||||
| FirstName: | SHITALDAS | ||||||||
| MiddleName: | JAMANDAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 PARK AVE E | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613563903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158752811 | ||||||||
| FaxNumber: | 8158762119 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 PARK AVE E | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158754531 | ||||||||
| FaxNumber: | 8158762118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2016 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TRN23676 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036149196 | 05 | IL | MEDICAID |