Healthcare Provider Details

I. General information

NPI: 1790742195
Provider Name (Legal Business Name): SUBODH C DESAI MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 OAK PARK AVE
BERWYN IL
60402-1718
US

IV. Provider business mailing address

2137 OAK PARK AVE
BERWYN IL
60402-1718
US

V. Phone/Fax

Practice location:
  • Phone: 708-746-4660
  • Fax: 708-749-4665
Mailing address:
  • Phone: 708-746-4660
  • Fax: 708-749-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ALAN HESTER
Title or Position: BILLER
Credential:
Phone: 773-827-7000