Provider Demographics
NPI:1508955956
Name:BANSAL, TINA C (MD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:C
Last Name:BANSAL
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 1:800 E WOODFIELD RD STE 113
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4786
Mailing Address - Country:US
Mailing Address - Phone:847-686-6866
Mailing Address - Fax:847-706-9891
Practice Address - Street 1:800 E WOODFIELD RD STE 113
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4786
Practice Address - Country:US
Practice Address - Phone:847-686-6866
Practice Address - Fax:847-706-9891
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112667207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202189914OtherTAX IDENTIFICATION
IL036112667Medicaid
IL036112667Medicaid
IL202189914OtherTAX IDENTIFICATION