Provider Demographics
NPI:1689743783
Name:RENUKA H BHATT MDSC
Entity Type:Organization
Organization Name:RENUKA H BHATT MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENUKA
Authorized Official - Middle Name:H
Authorized Official - Last Name:BHATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-676-5310
Mailing Address - Street 1:2202 ESSINGTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1634
Mailing Address - Country:US
Mailing Address - Phone:815-676-5307
Mailing Address - Fax:815-725-1321
Practice Address - Street 1:2202 ESSINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1634
Practice Address - Country:US
Practice Address - Phone:815-676-5307
Practice Address - Fax:815-725-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086915207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG12953Medicare ID - Type Unspecified