Provider Demographics
NPI:1265498463
Name:SHANMUGAM LAKSHMANAN SC
Entity Type:Organization
Organization Name:SHANMUGAM LAKSHMANAN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANMUGAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKSHMANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-548-5061
Mailing Address - Street 1:111 E ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2902
Mailing Address - Country:US
Mailing Address - Phone:618-548-5061
Mailing Address - Fax:618-568-5079
Practice Address - Street 1:111 E ROGERS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2902
Practice Address - Country:US
Practice Address - Phone:618-548-5061
Practice Address - Fax:618-568-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILOH2617602208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051027Medicaid
C44381Medicare UPIN
IL036051027Medicaid