Individual
SUSHANE GUPTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
17800 KEDZIE AVE, HAZEL CREST, IL 60429-2029
(708) 213-4200
(708) 213-0144
Mailing address
29373 NETWORK PL, CHICAGO, IL 60673-1293
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
036159430
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036-159430
LICENSE
IL
Enumeration date
04/19/2019
Last updated
07/03/2023
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