Provider Demographics
NPI:1922365170
Name:BHALLA, SAMIR (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:BHALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 HARRISON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1953
Mailing Address - Country:US
Mailing Address - Phone:708-632-5600
Mailing Address - Fax:708-632-5602
Practice Address - Street 1:4415 HARRISON ST STE 300
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1953
Practice Address - Country:US
Practice Address - Phone:630-988-0152
Practice Address - Fax:708-632-5602
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036138458207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine