Basic Information
| Provider Information | |||||||||
| NPI: | 1669413621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KASBEKAR | ||||||||
| FirstName: | AJITA | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600450631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476152200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2800 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084226200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036051158 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 036051158 | IL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036051158 | 05 | IL | MEDICAID |