Provider Demographics
NPI:1710680459
Name:TRIVEDI, RUJU VIVEK
Entity type:Individual
Prefix:
First Name:RUJU
Middle Name:VIVEK
Last Name:TRIVEDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W COURT ST STE 214
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3674
Mailing Address - Country:US
Mailing Address - Phone:815-928-6131
Mailing Address - Fax:
Practice Address - Street 1:555 W COURT ST STE 214
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3674
Practice Address - Country:US
Practice Address - Phone:815-928-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085010923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant