Basic Information
| Provider Information | |||||||||
| NPI: | 1073829990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHANUSHALI | ||||||||
| FirstName: | GAUTAM | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 W 68TH STREET | ||||||||
| Address2: | PROFESSIONAL PAVILION 4 SOUTH | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737354884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2010 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036132193 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 922820024 | 01 | IL | MEDICARE | OTHER |