Healthcare Provider Details

I. General information

NPI: 1861582694
Provider Name (Legal Business Name): GOSHEN MEDICAL PRACTICE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 KARISA DR SUITE1
GOSHEN IN
46526-6943
US

IV. Provider business mailing address

2240 KARISA DR SUITE1
GOSHEN IN
46526-6943
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-6757
  • Fax: 574-537-0357
Mailing address:
  • Phone: 574-534-6757
  • Fax: 574-537-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01054743A
License Number StateIN

VIII. Authorized Official

Name: DR. DICKY G BHAGAT
Title or Position: SOLE PROPERITOR OF LLC
Credential: M.D.
Phone: 574-534-6757