Provider Demographics
NPI:1396744868
Name:KESAVAN, B. S (MD)
Entity type:Individual
Prefix:
First Name:B.
Middle Name:S
Last Name:KESAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRAMANDASWAMY
Other - Middle Name:
Other - Last Name:SHANMUGAKESAVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-342-2171
Mailing Address - Fax:309-342-7205
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-342-2171
Practice Address - Fax:309-342-7205
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360524181Medicaid
K09399Medicare PIN
IL209766Medicare ID - Type Unspecified
IL0360524181Medicaid