Healthcare Provider Details

I. General information

NPI: 1225729650
Provider Name (Legal Business Name): RISHI MANISH BOTHARA M.B.B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N.E. GLEN OAK AVE
PEORIA IL
61637
US

IV. Provider business mailing address

OSF ST. FRANCIS MEDICAL CENTER, 530 NE GLEN OAK AVE INTERNAL MEDICINE RESIDENCY
PEORIA IL
61637
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-9351
  • Fax: 309-655-7732
Mailing address:
  • Phone: 309-624-9351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036177264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: