Basic Information
| Provider Information | |||||||||
| NPI: | 1689686958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAYANTHI RAMADURAI MD SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 798 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600680798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476926218 | ||||||||
| FaxNumber: | 8476925609 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 W 79TH ST | ||||||||
| Address2: | SUITE 2-3 | ||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086361177 | ||||||||
| FaxNumber: | 7086368741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAMADURAI | ||||||||
| AuthorizedOfficialFirstName: | JAYANTHI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8476926218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0360738093 | 05 | IL | MEDICAID | 216-22939 | 01 | BC BS | OTHER |