MEDICARE: ISHANI HARSH DALAL D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0802X	Addiction Psychiatry Physician	02004958A	IN
2	2084P0802X	Addiction Psychiatry Physician	036138180	IL

General Provider Information

NPI Number	:	1013141803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISHANI HARSH DALAL D.O.

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR STE 800
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-8701
Country	:	US
Telephone Number	:	877-879-3312
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 N LAKE SHORE DR STE 800
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-8701
Country	:	US
Telephone Number	:	773-417-9314
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2009
Last Update Date	:	12/11/2018

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