Provider Demographics
NPI:1053293415
Name:1801075429
Entity type:Organization
Organization Name:1801075429
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHUSWAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-562-6209
Mailing Address - Street 1:7531 S STONY ISLAND AVE STE 169
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3954
Mailing Address - Country:US
Mailing Address - Phone:773-947-7715
Mailing Address - Fax:773-947-7715
Practice Address - Street 1:7531 S STONY ISLAND AVE STE 169
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:773-947-7715
Practice Address - Fax:773-947-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty