1023177128 NPI number — GAUTAM GUPTA

Table of content: (NPI 1023177128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023177128 NPI number — GAUTAM GUPTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAUTAM GUPTA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023177128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6090 STRATHMOOR DR
Provider Second Line Business Mailing Address:
SUITE #4
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-6628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-229-1899
Provider Business Mailing Address Fax Number:
815-231-1218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6090 STRATHMOOR DR
Provider Second Line Business Practice Location Address:
SUITE #4
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-6628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-229-1899
Provider Business Practice Location Address Fax Number:
815-231-1218
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
GAUTAM
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
815-229-1899

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0010100611 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com