Basic Information
| Provider Information | |||||||||
| NPI: | 1811976954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRA | ||||||||
| FirstName: | AMITABHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DESPLAINES ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606615500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 3126549930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 N ARLINGTON HEIGHTS RD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600044830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473941843 | ||||||||
| FaxNumber: | 8473941208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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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 | 207RN0300X | 036114006 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036114006 | 05 | IL | MEDICAID |