Healthcare Provider Details

I. General information

NPI: 1760004345
Provider Name (Legal Business Name): BASHARATH ALI KHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE STE 331
CHICAGO IL
60625-3687
US

IV. Provider business mailing address

5145 N CALIFORNIA AVE STE 331
CHICAGO IL
60625-3687
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-989-1734
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-989-1734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036165738
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036165738
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: