Healthcare Provider Details

I. General information

NPI: 1871552885
Provider Name (Legal Business Name): MANEESHA BHATT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1285
  • Fax:
Mailing address:
  • Phone: 217-366-1285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036119010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: