Provider Demographics
NPI:1902640287
Name:MODI, CHINMAYA
Entity type:Individual
Prefix:
First Name:CHINMAYA
Middle Name:
Last Name:MODI
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 1:1089 GROTON CT
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3744
Mailing Address - Country:US
Mailing Address - Phone:847-660-9521
Mailing Address - Fax:
Practice Address - Street 1:600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1947
Practice Address - Country:US
Practice Address - Phone:800-238-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029609208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine