Basic Information
| Provider Information | |||||||||
| NPI: | 1245423573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | AMIT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HACKENSACK UNIVERSITY MEDICAL CENTER | ||||||||
| Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519963192 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PT0002X | 25MA09613900 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | 036157347 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25MA09613900 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02969708 | 05 | NY | MEDICAID |