Provider Demographics
NPI:1174711287
Name:PREM N PAHWA MD SC
Entity type:Organization
Organization Name:PREM N PAHWA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREM
Authorized Official - Middle Name:NATH
Authorized Official - Last Name:PAHWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-685-3846
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 134
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:773-685-3846
Mailing Address - Fax:773-685-7264
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 134
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-685-3846
Practice Address - Fax:773-685-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07282Medicaid
ILC41953Medicare UPIN