Healthcare Provider Details

I. General information

NPI: 1730163676
Provider Name (Legal Business Name): MANI N SUBRAMANIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RIVER RD SUITE #240
DES PLAINES IL
60016-1272
US

IV. Provider business mailing address

1872 BIG BEND DR
DES PLAINES IL
60016-3517
US

V. Phone/Fax

Practice location:
  • Phone: 847-391-9877
  • Fax: 847-391-9177
Mailing address:
  • Phone: 847-640-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036058679
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: