Provider Demographics
NPI:1083803902
Name:MOHANA HEALTHCARE INC
Entity Type:Organization
Organization Name:MOHANA HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BHARGAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:NETTEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-731-5466
Mailing Address - Street 1:5843 N SAINT JOHNS CT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3641 E 108TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6951
Practice Address - Country:US
Practice Address - Phone:773-731-5466
Practice Address - Fax:773-731-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103788Medicaid
IL036103788Medicaid
ILH47517Medicare UPIN