Provider Demographics
NPI:1316988397
Name:GHANI, EHTESHAM J (MD)
Entity type:Individual
Prefix:
First Name:EHTESHAM
Middle Name:J
Last Name:GHANI
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 1:9223 OGDEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513
Mailing Address - Country:US
Mailing Address - Phone:708-485-4050
Mailing Address - Fax:708-485-9216
Practice Address - Street 1:9223 OGDEN AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513
Practice Address - Country:US
Practice Address - Phone:708-485-4050
Practice Address - Fax:708-485-9216
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092503Medicaid
01623766OtherBLUE CROSS BLUE SHIELD
IL036092503Medicaid
G43375Medicare UPIN