MEDICARE: DATTA SAMBARE MD SC

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	261QP2300X	Primary Care Clinic/Center	036-129147	IL

General Provider Information

NPI Number	:	1790115517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DATTA SAMBARE MD SC

Provider Business Mailing Address
First Line	:	PO BOX 215
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-0215
Country	:	US
Telephone Number	:	708-613-4738
Fax Number	:

Provider Business Practice Location Address
First Line	:	6957 NORTH AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1068
Country	:	US
Telephone Number	:	708-613-4738
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DATTA SAMBARE
Credential	:	M.D.
Telephone Number	:	708-613-4738

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	07/07/2015

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