Provider Demographics
NPI:1114198223
Name:CHHANGANI, BANTU SAMRIDHI (MD)
Entity Type:Individual
Prefix:
First Name:BANTU
Middle Name:SAMRIDHI
Last Name:CHHANGANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 OAK TREE CT
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1978
Mailing Address - Country:US
Mailing Address - Phone:708-408-1101
Mailing Address - Fax:
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342
Practice Address - Country:US
Practice Address - Phone:219-942-0551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070080A207R00000X, 207RS0012X
MI4301081132207R00000X, 207RS0012X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114198223Medicaid
MIP32930286Medicare PIN
P32930286Medicare PIN
MIC97618161Medicare PIN