Basic Information
| Provider Information | |||||||||
| NPI: | 1417994013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANDHI | ||||||||
| FirstName: | BHAVESH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BOULEVARD | ||||||||
| Address2: | SUITE 100 (ATTN: MELVONNE JONES) | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157737827 | ||||||||
| FaxNumber: | 8158382656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 ESSINGTON RD STE 290 | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604352842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157737827 | ||||||||
| FaxNumber: | 1525484428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49061 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036-120708 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036120708 | 05 | IL | MEDICAID |