Healthcare Provider Details

I. General information

NPI: 1326334103
Provider Name (Legal Business Name): GITANJALI SIVASUBRAMANIAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

IV. Provider business mailing address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

V. Phone/Fax

Practice location:
  • Phone: 773-836-2785
  • Fax: 773-836-7381
Mailing address:
  • Phone: 773-836-2785
  • Fax: 773-836-7381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125060230
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036134988
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: