Provider Demographics
NPI:1265488647
Name:ANCHA, BASAVA (MD)
Entity Type:Individual
Prefix:DR
First Name:BASAVA
Middle Name:
Last Name:ANCHA
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 1:2740 W FOSTER AVE
Mailing Address - Street 2:LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3500
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:ICU
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
K26778OtherPTAN
IL036085594Medicaid
IL036085594Medicare ID - Type Unspecified
R00772Medicare PIN
BA3448570OtherDEA