Provider Demographics
NPI:1891906269
Name:HINSDALE HEALTH AND NUTRITION
Entity Type:Organization
Organization Name:HINSDALE HEALTH AND NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EHTESHAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-325-5185
Mailing Address - Street 1:120 E OGDEN AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3545
Mailing Address - Country:US
Mailing Address - Phone:630-325-5185
Mailing Address - Fax:630-325-5184
Practice Address - Street 1:120 E OGDEN AVE STE 120
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3545
Practice Address - Country:US
Practice Address - Phone:630-325-5185
Practice Address - Fax:630-325-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092503133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232961OtherBCBS IL
IL593010Medicare PIN