Healthcare Provider Details

I. General information

NPI: 1083906382
Provider Name (Legal Business Name): GAGANDEEP GOYAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5504 N 2ND ST
LOVES PARK IL
61111
US

IV. Provider business mailing address

1110 EAGLES NEST LN
MONROEVILLE PA
15146-1754
US

V. Phone/Fax

Practice location:
  • Phone: 815-977-4516
  • Fax:
Mailing address:
  • Phone: 267-226-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD438154
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number036.144684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: