Basic Information
Provider Information
NPI: 1003801291
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PATEL
FirstName: SAMIR
MiddleName: B
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 620 W EDISON RD
Address2: SUITE 110
City: MISHAWAKA
State: IN
PostalCode: 465452784
CountryCode: US
TelephoneNumber: 5742581100
FaxNumber: 5742581101
Practice Location
Address1: 620 W EDISON RD
Address2: SUITE 110
City: MISHAWAKA
State: IN
PostalCode: 465452784
CountryCode: US
TelephoneNumber: 5742581100
FaxNumber: 5742581101
Other Information
ProviderEnumerationDate: 09/14/2005
LastUpdateDate: 05/16/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085B0100X01046230INN Allopathic & Osteopathic PhysiciansRadiologyBody Imaging
2085N0700X01046230INN Allopathic & Osteopathic PhysiciansRadiologyNeuroradiology
2085N0904X01046230INN Allopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
2085P0229X01046230INN Allopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
2085R0202X01046230INY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0203X01046230INN Allopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
2085R0204X01046230INN Allopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
2085U0001X01046230INN Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound

ID Information
IDTypeStateIssuerDescription
20028018005IN MEDICAID


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