MEDICARE: DOWN THERE UROLOGY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center
2	208800000X	Urology Physician

General Provider Information

NPI Number	:	1265142129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWN THERE UROLOGY, PLLC

Provider Business Mailing Address
First Line	:	20706 CARDINAL CT
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-3106
Country	:	US
Telephone Number	:	312-620-1803
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 N CLARK ST STE 310
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-5413
Country	:	US
Telephone Number	:	312-620-1803
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	JAGAN KANSAL
Credential	:	MD
Telephone Number	:	312-620-1803

Provider Enumeration Date	:	12/01/2022
Last Update Date	:	12/10/2022

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