Healthcare Provider Details

I. General information

NPI: 1508076225
Provider Name (Legal Business Name): EHTESHAM J GHANI MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/02/2014
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: DR. EHTESHAM J GHANI
Title or Position: CLINICAL DIRECTOR
Credential: M.D
Phone: 708-485-4050