Provider Demographics
NPI:1205922770
Name:MUTHUSWAMY, PETHAM (MD)
Entity type:Individual
Prefix:DR
First Name:PETHAM
Middle Name:
Last Name:MUTHUSWAMY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7531 SOUTH STONY ISLAND
Mailing Address - Street 2:SUITE 169
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649
Mailing Address - Country:US
Mailing Address - Phone:773-947-7715
Mailing Address - Fax:773-643-0175
Practice Address - Street 1:7531 SOUTH STONY ISLAND
Practice Address - Street 2:SUITE 169
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649
Practice Address - Country:US
Practice Address - Phone:773-947-7715
Practice Address - Fax:773-643-0175
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047024207R00000X
IL03604724207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202773OtherUNITED HEALTH CARE
TN3048491OtherBCBS OF TN
IL0002201085OtherBLUE CROSS BLUE SHIELD
IL362993972OtherTAX ID #
IL362993972OtherCOMMERCIAL INSURANCES
IL110017592OtherTRM
IL4880209OtherSHARE
IL46K13OtherEMPIRE BCBS
IL036047024Medicaid
IL036047024Medicaid
ILAM5428950OtherDEA
IL110017592OtherTRM