Provider Demographics
NPI:1790709343
Name:GEPHART, ANANDITA GOEL (MD)
Entity Type:Individual
Prefix:
First Name:ANANDITA
Middle Name:GOEL
Last Name:GEPHART
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 1:1975 LIN LOR LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4902
Mailing Address - Country:US
Mailing Address - Phone:847-742-4111
Mailing Address - Fax:847-742-4545
Practice Address - Street 1:1975 LIN LOR LN
Practice Address - Street 2:SUITE 205
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-742-4111
Practice Address - Fax:847-742-4545
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094388207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094388Medicaid
ILG56572Medicare UPIN
IL580640Medicare ID - Type Unspecified