Provider Demographics
NPI:1417942228
Name:GHOREISHI, EASA (MD)
Entity type:Individual
Prefix:
First Name:EASA
Middle Name:
Last Name:GHOREISHI
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 1:810 MICHAEL DR
Mailing Address - Street 2:SUITE I
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2694
Mailing Address - Country:US
Mailing Address - Phone:219-395-2142
Mailing Address - Fax:219-929-4292
Practice Address - Street 1:810 MICHAEL DR
Practice Address - Street 2:SUITE I
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2694
Practice Address - Country:US
Practice Address - Phone:219-395-2142
Practice Address - Fax:219-929-4292
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050773A207P00000X, 207QA0000X
CAC147933207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00258168OtherRR MEDICARE
IN000000371646OtherANTHEM
IN200317290Medicaid
IN000000371646OtherANTHEM
IN862280XXMedicare PIN
G91104Medicare UPIN
IL$$$$$$$$$Medicare PIN
5710110004Medicare NSC
IN193810EMedicare PIN