Healthcare Provider Details

I. General information

NPI: 1265498463
Provider Name (Legal Business Name): SHANMUGAM LAKSHMANAN SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E ROGERS ST
SALEM IL
62881-2902
US

IV. Provider business mailing address

111 E ROGERS ST
SALEM IL
62881-2902
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-5061
  • Fax: 618-568-5079
Mailing address:
  • Phone: 618-548-5061
  • Fax: 618-568-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberOH2617602
License Number StateIL

VIII. Authorized Official

Name: DR. SHANMUGAM LAKSHMANAN
Title or Position: PRESIDENT
Credential: MD
Phone: 618-548-5061