Provider Demographics
NPI:1962567651
Name:AJAY A MADHANI MD SC
Entity type:Organization
Organization Name:AJAY A MADHANI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MADHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-642-3781
Mailing Address - Street 1:200 SOUTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-3209
Mailing Address - Country:US
Mailing Address - Phone:847-642-3781
Mailing Address - Fax:
Practice Address - Street 1:755 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 263
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3253
Practice Address - Country:US
Practice Address - Phone:847-367-0787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-25
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042 007596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL087144Medicaid
IL999640Medicare ID - Type Unspecified
IL087144Medicaid