Basic Information
Provider Information | |||||||||
NPI: | 1013174598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AHUJA | ||||||||
FirstName: | NARESH | ||||||||
MiddleName: | KUMAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 675 | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IL | ||||||||
PostalCode: | 628640014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183156466 | ||||||||
FaxNumber: | 6183156469 | ||||||||
Practice Location | |||||||||
Address1: | 4230 LINCOLNSHIRE DR STE A | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IL | ||||||||
PostalCode: | 628642189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183156466 | ||||||||
FaxNumber: | 6183156469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2008 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD434356 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208600000X | 036124910 | IL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 721089 | 01 | IL | AETNA | OTHER | 3932056 | 01 | IL | BCBS | OTHER | 036124910 | 05 | IL |   | MEDICAID |