MEDICARE: DR. VAISHNAVI KUTA GANESAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	TEP8872	NE
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	125.087139	IL
3	207RP1001X	Pulmonary Disease Physician	2023019979	MO

General Provider Information

NPI Number	:	1265041818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VAISHNAVI KUTA GANESAN MD

Provider Business Mailing Address
First Line	:	5758 S MARYLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1426
Country	:	US
Telephone Number	:	888-824-0200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5758 S MARYLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1426
Country	:	US
Telephone Number	:	888-824-0200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	06/18/2026

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