Healthcare Provider Details

I. General information

NPI: 1467773960
Provider Name (Legal Business Name): SIVA KUMAR ELANGOVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR STE 1425
CHICAGO IL
60611-4451
US

IV. Provider business mailing address

545 VALLEY VIEW DRIVE
MOLINE IL
61265
US

V. Phone/Fax

Practice location:
  • Phone: 312-480-1387
  • Fax:
Mailing address:
  • Phone: 309-762-5560
  • Fax: 309-277-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR-8953
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.136046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: