Provider Demographics
NPI:1497725345
Name:MUKERJI, BASANTI (MD)
Entity Type:Individual
Prefix:
First Name:BASANTI
Middle Name:
Last Name:MUKERJI
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 1:5850 S 6TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5162
Mailing Address - Country:US
Mailing Address - Phone:217-529-5046
Mailing Address - Fax:217-529-6154
Practice Address - Street 1:5850 S 6TH STREET RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5162
Practice Address - Country:US
Practice Address - Phone:217-529-5046
Practice Address - Fax:217-529-6154
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76732207R00000X
IL036060643207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL133586700OtherACS-OWCP
IL6394POtherCATERPILLAR
IL14D0949277OtherCLIA PGW
IL08421024OtherBC OF IL
IL14D0435365OtherCLIA CFP
IL020057300OtherBLACK LUNG
ILCD7143OtherRR MEDICARE GRP
IL233260Medicare PIN
IL6394POtherCATERPILLAR
IL209581Medicare PIN