Provider Demographics
NPI:1073555488
Name:KUGANESWARAN, ELIATHAMBY (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIATHAMBY
Middle Name:
Last Name:KUGANESWARAN
Suffix:
Gender:M
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0365
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-671-2944
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1276
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-671-2944
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105345207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105345Medicaid
IL100015542OtherRAILROAD MEDICARE
IL071696OtherHEALTH ALLIANCE
IL371221637OtherFEDERAL TAX IDENTIFICATIO
IL658303OtherHEALTHLINK
IL07215152OtherBLUE CROSS
IL776530OtherMEDICARE GROUP NUMBER
IL7991429OtherAETNA HEALTH PLANS
ILIL0117OtherJOHN DEERE
ILL87576Medicare ID - Type Unspecified
IL071696OtherHEALTH ALLIANCE