Basic Information
| Provider Information | |||||||||
| NPI: | 1215030481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | MADAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093441000 | ||||||||
| FaxNumber: | 3093441054 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093441000 | ||||||||
| FaxNumber: | 3093441054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 364271985-10 | 01 | JOHN DEERE | OTHER | 4815127 | 01 | BC/BS | OTHER | 0581348 | 01 | ACS | OTHER | 10589098 | 01 | CAQH | OTHER | 4319343 | 01 | AETNA | OTHER |