Healthcare Provider Details

I. General information

NPI: 1457587172
Provider Name (Legal Business Name): SHISHIRA S BHARADWAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2490 S WOODWORTH LOOP STE 200
PALMER AK
99645-7410
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone: 630-639-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036154430
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD28709
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number285007
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA156145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: