Healthcare Provider Details

I. General information

NPI: 1639206535
Provider Name (Legal Business Name): GURCHARAN S RANDHAWA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 N NORTH BRANCH ST SUITE 210
CHICAGO IL
60642-2473
US

IV. Provider business mailing address

1229 N NORTH BRANCH ST SUITE 210
CHICAGO IL
60642-2473
US

V. Phone/Fax

Practice location:
  • Phone: 312-939-5090
  • Fax: 312-640-4496
Mailing address:
  • Phone: 312-939-5090
  • Fax: 312-640-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number27214
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036085519
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number01038819A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: