Provider Demographics
NPI:1659406510
Name:WADHWANI, SURESH H (MD SC)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:H
Last Name:WADHWANI
Suffix:
Gender:M
Credentials:MD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W COURT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3679
Mailing Address - Country:US
Mailing Address - Phone:815-936-3250
Mailing Address - Fax:815-936-3253
Practice Address - Street 1:100 PROVENA WAY
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4796
Practice Address - Country:US
Practice Address - Phone:815-936-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073974207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073974Medicaid
ILE78759Medicare UPIN
IL211115Medicare ID - Type UnspecifiedGROUP
ILK03149Medicare PIN
ILK15288Medicare ID - Type Unspecified
IL036073974Medicaid