Provider Demographics
NPI:1447297890
Name:MEHROTRA, SURABHI (MD)
Entity type:Individual
Prefix:
First Name:SURABHI
Middle Name:
Last Name:MEHROTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W JACKSON BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3227
Mailing Address - Country:US
Mailing Address - Phone:312-942-8000
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:312-942-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114308207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-114308Medicaid