Provider Demographics
NPI:1366096315
Name:PATIL, KAUSHAL MAHIPATI
Entity type:Individual
Prefix:
First Name:KAUSHAL
Middle Name:MAHIPATI
Last Name:PATIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:506 E. SOUTHWAY BLVD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3820
Practice Address - Country:US
Practice Address - Phone:765-626-0299
Practice Address - Fax:765-864-2070
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012721A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist