Basic Information
| Provider Information | |||||||||
| NPI: | 1417942228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHOREISHI | ||||||||
| FirstName: | EASA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 MICHAEL DR | ||||||||
| Address2: | SUITE I | ||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463042694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193952142 | ||||||||
| FaxNumber: | 2199294292 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 MICHAEL DR | ||||||||
| Address2: | SUITE I | ||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463042694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193952142 | ||||||||
| FaxNumber: | 2199294292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | 01050773A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207P00000X | 01050773A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000371646 | 01 | IN | ANTHEM | OTHER | 200317290 | 05 | IN | MEDICAID | P00258168 | 01 | RR MEDICARE | OTHER |