Basic Information
| Provider Information | |||||||||
| NPI: | 1659320950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANDHI | ||||||||
| FirstName: | ROMAL | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S. 80TH AVENUE | ||||||||
| Address2: | MED STAFF OFFICE SUITE 1630 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S. 80TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235869 | ||||||||
| FaxNumber: | 7089235859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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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 | 207R00000X | 036-109071 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036.109071 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | F40081751 | 01 | IL | MEDICARE PTAN | OTHER | 036109071 | 05 | IL | MEDICAID |