Provider Demographics
NPI:1669473963
Name:BHALALA, GOPAL N (MD)
Entity Type:Individual
Prefix:DR
First Name:GOPAL
Middle Name:N
Last Name:BHALALA
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 1:2024 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:847-872-3000
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:847-872-3000
Practice Address - Fax:847-872-7202
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-09-10
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IL036-072139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072139Medicaid
IL036072139Medicaid
IL754840Medicare PIN