Healthcare Provider Details

I. General information

NPI: 1053293415
Provider Name (Legal Business Name): 1801075429
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE STE 169
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

7531 S STONY ISLAND AVE STE 169
CHICAGO IL
60649-3954
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7715
  • Fax: 773-947-7715
Mailing address:
  • Phone: 773-947-7715
  • Fax: 773-947-7715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETHAM MUTHUSWAMY
Title or Position: PRESIDENT
Credential: MD
Phone: 773-562-6209