Healthcare Provider Details

I. General information

NPI: 1821149238
Provider Name (Legal Business Name): SANJAY GANDHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 12/18/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 GREENLEAF AVE STE E
PARK CITY IL
60085-5701
US

IV. Provider business mailing address

351 GREENLEAF AVE STE E
PARK CITY IL
60085-5701
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-1100
  • Fax: 847-775-0703
Mailing address:
  • Phone: 847-234-1100
  • Fax: 847-775-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036101308
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036101308
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036-101308
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: