MEDICARE: GUPTA MEDICAL CLINIC LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036100728	IL

General Provider Information

NPI Number	:	1942352547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUPTA MEDICAL CLINIC LTD

Provider Business Mailing Address
First Line	:	284 MEMORIAL CT STE B
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-459-8240
Fax Number	:	815-459-8470

Provider Business Practice Location Address
First Line	:	284 MEMORIAL CT STE B
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-459-8240
Fax Number	:	815-459-8470

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SANJEEV GUPTA
Credential	:	MD
Telephone Number	:	815-459-8240

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	11/12/2009

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