Healthcare Provider Details

I. General information

NPI: 1790233609
Provider Name (Legal Business Name): RONNIE MANDAL DO, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE STE 101
CHICAGO IL
60625-3547
US

IV. Provider business mailing address

6634 N TRUMBULL AVE
LINCOLNWOOD IL
60712-3738
US

V. Phone/Fax

Practice location:
  • Phone: 773-545-9500
  • Fax:
Mailing address:
  • Phone: 847-757-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number036119779
License Number StateIL

VIII. Authorized Official

Name: DR. RONNIE RANJAN MANDAL
Title or Position: PRESIDENT
Credential: DO
Phone: 847-757-5880