Provider Demographics
NPI:1649247784
Name:VERGHESE, GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:VERGHESE
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 1:555 W COURT ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3664
Mailing Address - Country:US
Mailing Address - Phone:815-802-8031
Mailing Address - Fax:
Practice Address - Street 1:555 W COURT ST
Practice Address - Street 2:SUITE 403
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3664
Practice Address - Country:US
Practice Address - Phone:815-802-8031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101532207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101532Medicaid
ILK08382Medicare ID - Type Unspecified
IL036101532Medicaid
H09160Medicare UPIN