Provider Demographics
NPI:1861582694
Name:GOSHEN MEDICAL PRACTICE,LLC
Entity type:Organization
Organization Name:GOSHEN MEDICAL PRACTICE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPERITOR OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:DICKY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BHAGAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-534-6757
Mailing Address - Street 1:2240 KARISA DR
Mailing Address - Street 2:SUITE1
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6943
Mailing Address - Country:US
Mailing Address - Phone:574-534-6757
Mailing Address - Fax:574-537-0357
Practice Address - Street 1:2240 KARISA DR
Practice Address - Street 2:SUITE1
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6943
Practice Address - Country:US
Practice Address - Phone:574-534-6757
Practice Address - Fax:574-537-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054743A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN213940AMedicare ID - Type Unspecified