Healthcare Provider Details

I. General information

NPI: 1992118624
Provider Name (Legal Business Name): NEEL GOPAL BHALALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 LEWIS AVE
ZION IL
60099-1546
US

IV. Provider business mailing address

2024 LEWIS AVE
ZION IL
60099-1546
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-5911
  • Fax: 847-872-7202
Mailing address:
  • Phone: 847-872-5911
  • Fax: 847-872-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.147760
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-09912
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: