Healthcare Provider Details

I. General information

NPI: 1891137501
Provider Name (Legal Business Name): BHAVNA GUPTA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST STE 250N
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1041
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-5313
  • Fax: 847-723-2338
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-140656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: