Provider Demographics
NPI:1568878221
Name:TEJASI GHOLAP MD SC
Entity Type:Organization
Organization Name:TEJASI GHOLAP MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEJASI
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOLAP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-736-7583
Mailing Address - Street 1:2350 COUNTY FARM LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-4807
Mailing Address - Country:US
Mailing Address - Phone:414-736-7583
Mailing Address - Fax:
Practice Address - Street 1:901 CENTER ST
Practice Address - Street 2:SUITE 209
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2104
Practice Address - Country:US
Practice Address - Phone:847-429-1157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty