Provider Demographics
NPI:1619147279
Name:GUPTA, MADHU
Entity Type:Individual
Prefix:MISS
First Name:MADHU
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BIESTERFIELD ROAD
Mailing Address - Street 2:MEXIAN BROTHER CORPORATE HEALTH
Mailing Address - City:ELK GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60007
Mailing Address - Country:US
Mailing Address - Phone:847-981-5910
Mailing Address - Fax:847-956-5420
Practice Address - Street 1:136 BIESTERFIELD ROAD
Practice Address - Street 2:MEXIAN BROTHER CORPORATE HEALTH
Practice Address - City:ELK GROVE
Practice Address - State:IL
Practice Address - Zip Code:60007
Practice Address - Country:US
Practice Address - Phone:847-981-5910
Practice Address - Fax:847-956-5420
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist