Provider Demographics
NPI:1245277169
Name:SUBRAM, ASWATH (MD)
Entity type:Individual
Prefix:
First Name:ASWATH
Middle Name:
Last Name:SUBRAM
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 1:333 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1748
Mailing Address - Country:US
Mailing Address - Phone:708-756-0100
Mailing Address - Fax:708-709-6353
Practice Address - Street 1:3700 W 203RD ST
Practice Address - Street 2:#301
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1180
Practice Address - Country:US
Practice Address - Phone:708-709-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360561312086S0129X
IN01045324A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056131Medicaid
IN219160AMedicare ID - Type Unspecified
ILL95580Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 15
IL036056131Medicaid
ILL95579Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 16