Provider Demographics
NPI:1134192578
Name:PREMKUMAR, ASHVINI P (MD)
Entity type:Individual
Prefix:DR
First Name:ASHVINI
Middle Name:P
Last Name:PREMKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 PFINGSTEN RD STE 2000
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1339
Mailing Address - Country:US
Mailing Address - Phone:847-570-2570
Mailing Address - Fax:847-657-5708
Practice Address - Street 1:2180 PFINGSTEN RD STE 2000
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026
Practice Address - Country:US
Practice Address - Phone:847-570-2570
Practice Address - Fax:847-657-5708
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361214082084N0400X
AZ336742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ223888Medicaid
MN093469100Medicaid
AZP00625270OtherRAILROAD MEDICARE
AZ860800150 85259 B194OtherTRICARE
I30198Medicare UPIN
AZZ115737Medicare PIN
AZ860800150 85259 B194OtherTRICARE