Healthcare Provider Details

I. General information

NPI: 1891291886
Provider Name (Legal Business Name): GAUTHAM ANIL OROSKAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2000
  • Fax:
Mailing address:
  • Phone: 847-318-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036154163
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036154163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: