Healthcare Provider Details

I. General information

NPI: 1992758783
Provider Name (Legal Business Name): SHAILESH GANDHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

185 PENNY AVE
EAST DUNDEE IL
60118-1454
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-8000
  • Fax:
Mailing address:
  • Phone: 847-836-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036115483
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036115483
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number46167
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: