Provider Demographics
NPI:1144382201
Name:DHANALAKSHMI P. GANESAN M.D.S.C
Entity Type:Organization
Organization Name:DHANALAKSHMI P. GANESAN M.D.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DHANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GANESAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-405-6200
Mailing Address - Street 1:7357 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1230
Mailing Address - Country:US
Mailing Address - Phone:708-405-6200
Mailing Address - Fax:708-405-6223
Practice Address - Street 1:7357 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1230
Practice Address - Country:US
Practice Address - Phone:708-405-6200
Practice Address - Fax:708-405-6223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHANALAKSHMI P. GANESAN M.D.S.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-617802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094637Medicaid
IL208546Medicare PIN
ILG80594Medicare UPIN