Provider Demographics
NPI:1073682910
Name:BISLA, VIRENDRA (MD)
Entity Type:Individual
Prefix:
First Name:VIRENDRA
Middle Name:
Last Name:BISLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 OTIS BOWEN DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4158
Mailing Address - Country:US
Mailing Address - Phone:219-934-5300
Mailing Address - Fax:
Practice Address - Street 1:9011 S COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4304
Practice Address - Country:US
Practice Address - Phone:773-933-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047792Medicaid
ILK51805Medicare PIN
ILC41917Medicare UPIN
IL474640Medicare ID - Type Unspecified
IN867900Medicare PIN