Provider Demographics
NPI:1558620146
Name:KHISTY, RAUNAK SUNIL
Entity type:Individual
Prefix:
First Name:RAUNAK
Middle Name:SUNIL
Last Name:KHISTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2682
Mailing Address - Country:US
Mailing Address - Phone:815-937-1237
Mailing Address - Fax:815-933-0662
Practice Address - Street 1:400 S KENNEDY DR STE 300
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-2682
Practice Address - Country:US
Practice Address - Phone:815-937-1237
Practice Address - Fax:815-933-0662
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361442162084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty