Provider Demographics
NPI:1346371192
Name:GUSTAVO M. BANTI, M.D., LTD
Entity Type:Organization
Organization Name:GUSTAVO M. BANTI, M.D., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:BANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-377-1368
Mailing Address - Street 1:302 RANDALL RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4209
Mailing Address - Country:US
Mailing Address - Phone:630-377-1368
Mailing Address - Fax:630-377-7514
Practice Address - Street 1:302 RANDALL RD
Practice Address - Street 2:SUITE 306
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-377-1368
Practice Address - Fax:630-377-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063412208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063412Medicaid
IL4500628OtherBCBS
IL036063412Medicaid
IL208427Medicare PIN