Healthcare Provider Details

I. General information

NPI: 1245874635
Provider Name (Legal Business Name): CITY CENTER HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N OTTAWA ST
JOLIET IL
60432-4009
US

IV. Provider business mailing address

12 KIMBERLEY CIR
OAK BROOK IL
60523-1719
US

V. Phone/Fax

Practice location:
  • Phone: 815-726-0311
  • Fax: 815-726-0520
Mailing address:
  • Phone: 630-299-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANTHI R GOPI
Title or Position: PRESIDENT
Credential: MD
Phone: 815-726-0311