MEDICARE: DR. DATTA SAMBARE M.D.

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	207R00000X	Internal Medicine Physician	036094741	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	K11005	OTHER	IL	MEDICARE PIN - BROOKVILLE MEDICAL CENTER
3	K11006	OTHER	IL	MEDICARE PIN - MADISON PARKSIDE MEDICAL CENTER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619911211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DATTA SAMBARE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 215
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-0215
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5650 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3939
Country	:	US
Telephone Number	:	773-379-2304
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	12/27/2016

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