Provider Demographics
NPI:1508863655
Name:HATHIWALA, SURESH C (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:C
Last Name:HATHIWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1214 N KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1237
Mailing Address - Country:US
Mailing Address - Phone:708-383-6996
Mailing Address - Fax:773-257-6027
Practice Address - Street 1:CALIFORNIA AVE 15TH STREET
Practice Address - Street 2:DEPT OF MEDICINE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1797
Practice Address - Country:US
Practice Address - Phone:773-257-6552
Practice Address - Fax:773-257-6027
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616108OtherBCBS
ILC30486OtherRR MEDICARE GROUP
ILC30486OtherRR MEDICARE GROUP
ILH96288Medicare UPIN
IL922820Medicare ID - Type UnspecifiedGROUP NUMBER