Provider Demographics
NPI:1962457614
Name:GANAPATHI GOTTUMUKKALA
Entity Type:Organization
Organization Name:GANAPATHI GOTTUMUKKALA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GANAPATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTUMUKKALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-614-0893
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0849
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6701 159TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1758
Practice Address - Country:US
Practice Address - Phone:708-614-0893
Practice Address - Fax:708-342-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-074987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01625532OtherBCBSIL GROUP #
IL570900Medicare PIN
IL01625532OtherBCBSIL GROUP #