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General NPI Number Information
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NPI Number | 1215665294
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Entity Type | Individual
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Provider Name | MAHATHI KEELAPANDAL GANESH
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Gender | Female
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Dates
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Enumeration Date | 08/09/2022
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 611 W PARK ST
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City | URBANA
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State | IL
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Zip | 61801-2529
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Country | US
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Telephone | 217-383-3110
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Fax |
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Provider Business Mailing Address
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Address Line | 2927 FISHERMANS CV APT 203
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City | LAKE ORION
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State | MI
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Zip | 48360-2603
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Country | US
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Telephone | 248-607-0780
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125080023
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301513505
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License Number State | MI
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