Provider Demographics
NPI:1841252152
Name:SURESH H. WADHWANI, MD, SC
Entity type:Organization
Organization Name:SURESH H. WADHWANI, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:H
Authorized Official - Last Name:WADHWANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-936-3250
Mailing Address - Street 1:455 W COURT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3679
Mailing Address - Country:US
Mailing Address - Phone:815-936-3250
Mailing Address - Fax:815-936-3253
Practice Address - Street 1:455 W COURT ST
Practice Address - Street 2:SUITE 302
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3694
Practice Address - Country:US
Practice Address - Phone:815-936-3250
Practice Address - Fax:815-936-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073974207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB9171OtherRAILROAD MEDICARE
ILDC7793OtherRAILROAD MEDICARE
ILDC7793OtherRAILROAD MEDICARE
IL211115Medicare ID - Type UnspecifiedGROUP