Provider Demographics
NPI:1255584397
Name:GINNE, PURSHOTHAM R (MD)
Entity type:Individual
Prefix:
First Name:PURSHOTHAM
Middle Name:R
Last Name:GINNE
Suffix:
Gender:
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-865-2141
Practice Address - Fax:219-852-2502
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7046207R00000X
IN01069830A207R00000X, 208M00000X
IL125.054775207R00000X
COCDR.0002240207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ7046OtherSTATE LICENSE
TX1255584397OtherNPI
COCDR.0002240OtherSTATE LICENSE