MEDICARE: GURBACHAN S KAPOOR MD

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	2085R0001X	Radiation Oncology Physician	01026462A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00051342	OTHER	IN	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000000251277	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1396738209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GURBACHAN S KAPOOR MD

Provider Business Mailing Address
First Line	:	600 GRANT ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46402-6001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 AMERITECH DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9120
Country	:	US
Telephone Number	:	574-271-2558
Fax Number	:	574-273-1137

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

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	12/28/2007

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