Basic Information
| Provider Information | |||||||||
| NPI: | 1164411435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANERJI | ||||||||
| FirstName: | MANATOSH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25068 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606730001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475857000 | ||||||||
| FaxNumber: | 8472400622 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084504554 | ||||||||
| FaxNumber: | 7083446816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036044727 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036044727 | 05 | IL | MEDICAID |