Basic Information
| Provider Information | |||||||||
| NPI: | 1962639294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | ASHISH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5841 S MARYLAND AVE # MC-4028 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737026700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE # MC-4028 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737026700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2009 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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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 | 207L00000X | 60508 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | 036.135551 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 036.135551 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1962639294 | 05 | WI | MEDICAID |