Healthcare Provider Details

I. General information

NPI: 1487732103
Provider Name (Legal Business Name): NITIN P BHOSALE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 FOX DR STE 5
CHAMPAIGN IL
61820-7377
US

IV. Provider business mailing address

1408 ENGLISH OAK DR
CHAMPAIGN IL
61822-3351
US

V. Phone/Fax

Practice location:
  • Phone: 815-683-6109
  • Fax: 978-307-5504
Mailing address:
  • Phone: 217-766-5170
  • Fax: 978-307-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036118155
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number036118155
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number036118155
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: