Healthcare Provider Details

I. General information

NPI: 1316988397
Provider Name (Legal Business Name): EHTESHAM J GHANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9223 OGDEN AVENUE
BROOKFIELD IL
60513
US

IV. Provider business mailing address

9223 OGDEN AVENUE
BROOKFIELD IL
60513
US

V. Phone/Fax

Practice location:
  • Phone: 708-485-4050
  • Fax: 708-485-9216
Mailing address:
  • Phone: 708-485-4050
  • Fax: 708-485-9216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036092503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: