Provider Demographics
NPI:1164411435
Name:BANERJI, MANATOSH (MD)
Entity Type:Individual
Prefix:
First Name:MANATOSH
Middle Name:
Last Name:BANERJI
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 1:25068 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-0001
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:715 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-450-4554
Practice Address - Fax:708-344-6816
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044727207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044727Medicaid
IL218890Medicare PIN
ILT01548Medicare PIN
IL218860Medicare PIN
IL900001506Medicare PIN
ILL56364Medicare PIN
IL397530Medicare PIN
IL036044727Medicaid