Provider Demographics
NPI:1326249293
Name:GUPTA INTERNAL MEDICINE ASSOCIATES,S.C.
Entity Type:Organization
Organization Name:GUPTA INTERNAL MEDICINE ASSOCIATES,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:G
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-525-5008
Mailing Address - Street 1:222 E PEARSON ST
Mailing Address - Street 2:UNIT 2705
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-7347
Mailing Address - Country:US
Mailing Address - Phone:708-525-5008
Mailing Address - Fax:
Practice Address - Street 1:17850 SOUTH KEDZIE AVENUE
Practice Address - Street 2:SUITE 3300
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-799-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD2711OtherRAILROAD MEDICARE
1619980OtherBC/BS PROVIDER #
363490Medicare PIN