Basic Information
| Provider Information | |||||||||
| NPI: | 1508863655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATHIWALA | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1214 N KENILWORTH AVE | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603021237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083836996 | ||||||||
| FaxNumber: | 7732576027 | ||||||||
| Practice Location | |||||||||
| Address1: | CALIFORNIA AVE 15TH STREET | ||||||||
| Address2: | DEPT OF MEDICINE | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732576552 | ||||||||
| FaxNumber: | 7732576027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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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 | 207RN0300X | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1616108 | 01 | IL | BCBS | OTHER | C30486 | 01 | IL | RR MEDICARE GROUP | OTHER |