Healthcare Provider Details

I. General information

NPI: 1114094281
Provider Name (Legal Business Name): RAJIV KANDALA M D S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/07/2023
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND #152
CHICAGO IL
60649
US

IV. Provider business mailing address

1720 S MICHIGAN AVE APT 2909
CHICAGO IL
60616-4861
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-2831
  • Fax:
Mailing address:
  • Phone: 630-405-5500
  • Fax: 708-226-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJIV KANDALA
Title or Position: SECRETARY
Credential:
Phone: 773-793-4527