MEDICARE: SURESH C HATHIWALA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	C30486	OTHER	IL	RR MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1616108	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1508863655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURESH C HATHIWALA MD

Provider Business Mailing Address
First Line	:	1214 N KENILWORTH AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1237
Country	:	US
Telephone Number	:	708-383-6996
Fax Number	:	773-257-6027

Provider Business Practice Location Address
First Line	:	CALIFORNIA AVE 15TH STREET
Second Line	:	DEPT OF MEDICINE
City	:	CHICAGO
State	:	IL
Zip	:	60608-1797
Country	:	US
Telephone Number	:	773-257-6552
Fax Number	:	773-257-6027

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	09/06/2007

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Directions to “ SURESH C HATHIWALA MD” Practice Location

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