Healthcare Provider Details

I. General information

NPI: 1619404803
Provider Name (Legal Business Name): GOPAL N. BHALALA, M.D..LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 07/21/2022
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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036-072139
License Number StateIL

VIII. Authorized Official

Name: GOPAL N BHALALA
Title or Position: MD
Credential: MD
Phone: 847-872-5911