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Individual

TEJAL R. MODI

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
PA-C

Contact information

Practice address
2650 RIDGE AVE, EVANSTON, IL 60201-1718
(847) 570-2111
Mailing address
2650 RIDGE AVE, EVANSTON, IL 60201-1718

Taxonomy

Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
085-002793
IL STATE LIC
IL
Enumeration date
05/29/2007
Last updated
06/13/2016
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