Provider Demographics
NPI:1639206535
Name:RANDHAWA, GURCHARAN S (MD)
Entity Type:Individual
Prefix:
First Name:GURCHARAN
Middle Name:S
Last Name:RANDHAWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 N NORTH BRANCH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2473
Mailing Address - Country:US
Mailing Address - Phone:312-939-5090
Mailing Address - Fax:312-640-4496
Practice Address - Street 1:1229 N NORTH BRANCH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2473
Practice Address - Country:US
Practice Address - Phone:312-939-5090
Practice Address - Fax:312-640-4496
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27214174400000X
IL036085519207RG0300X
IN01038819A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E92170Medicare UPIN