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General NPI Number Information
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NPI Number | 1083803902
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Entity Type | Organization
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Legal Business Name | MOHANA HEALTH CARE LTD
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 3641 E 108TH ST
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City | CHICAGO
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State | IL
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Zip | 60617-6951
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Country | US
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Telephone | 773-731-5466
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Fax | 773-731-5461
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Provider Business Mailing Address
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Address Line | 5843 N SAINT JOHNS CT
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City | CHICAGO
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State | IL
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Zip | 60646-6048
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BHARGAVI NETTEM
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Credential | MD
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Telephone | 773-731-5466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036103788
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License Number State | IL
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