Healthcare Provider Details

I. General information

NPI: 1760776710
Provider Name (Legal Business Name): MAHESH VAIDYANATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST # F5-704 DEPARTMENT OF ANESTHESIA
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST # F5-704 DEPARTMENT OF ANESTHESIA
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0061
  • Fax:
Mailing address:
  • Phone: 312-695-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.137496
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: