Healthcare Provider Details

I. General information

NPI: 1962523720
Provider Name (Legal Business Name): GUPTA MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17850 SOUTH KEDZIE AVENUE SUITE 3300
HAZEL CREST IL
60429
US

IV. Provider business mailing address

222 E PEARSON ST UNIT 2705
CHICAGO IL
60611-7347
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-6055
  • Fax:
Mailing address:
  • Phone: 708-525-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJ G GUPTA
Title or Position: OWNER
Credential: MD
Phone: 708-525-5008