Provider Demographics
NPI:1730163676
Name:SUBRAMANIAN, MANI N (MD)
Entity type:Individual
Prefix:
First Name:MANI
Middle Name:N
Last Name:SUBRAMANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 BIG BEND DR
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-3517
Mailing Address - Country:US
Mailing Address - Phone:847-640-0513
Mailing Address - Fax:
Practice Address - Street 1:150 N RIVER RD
Practice Address - Street 2:SUITE #240
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1272
Practice Address - Country:US
Practice Address - Phone:847-391-9877
Practice Address - Fax:847-391-9177
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004405317OtherAETNA
IL01627643OtherBLUE CROSS BLUE SHIELD
IL036058679 3Medicaid
IL110248785OtherRAILROAD MEDICARE
IL036058679 3Medicaid
IL705860Medicare ID - Type Unspecified