Provider Demographics
NPI:1720179773
Name:BHATIA, PREM L (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:L
Last Name:BHATIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7757
Mailing Address - Country:US
Mailing Address - Phone:309-685-0100
Mailing Address - Fax:309-685-0172
Practice Address - Street 1:9118 N LINDBERGH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1422
Practice Address - Country:US
Practice Address - Phone:309-693-3993
Practice Address - Fax:309-693-8027
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL56850OtherPIN NUMBER
ILL56850OtherPIN NUMBER
ILF10616Medicare UPIN