Provider Demographics
NPI:1619404803
Name:GOPAL N. BHALALA, M.D..LLC
Entity Type:Organization
Organization Name:GOPAL N. BHALALA, M.D..LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GOPAL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BHALALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-872-5911
Mailing Address - Street 1:2024 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-1546
Mailing Address - Country:US
Mailing Address - Phone:847-872-5911
Mailing Address - Fax:847-872-7202
Practice Address - Street 1:2024 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-1546
Practice Address - Country:US
Practice Address - Phone:847-872-5911
Practice Address - Fax:847-872-7202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOPAL N. BHALALA MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072139261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072139Medicaid