Basic Information
Provider Information | |||||||||
NPI: | 1265965123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BHASKARLA | ||||||||
FirstName: | AMRIT | ||||||||
MiddleName: | VED | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2550 WATERVIEW DR | ||||||||
Address2: | UNIT 354 | ||||||||
City: | NORTHBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 600626366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154830971 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3001 GREEN BAY RD | ||||||||
Address2: |   | ||||||||
City: | NORTH CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 600643048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476881900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2017 | ||||||||
LastUpdateDate: | 06/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | B264-0189-0225 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.