Healthcare Provider Details

I. General information

NPI: 1184694259
Provider Name (Legal Business Name): ASSOCIATES IN NEPHROLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DESPLAINES ST
CHICAGO IL
60661-5500
US

IV. Provider business mailing address

4026 PAYSPHERE CIR
CHICAGO IL
60674-0400
US

V. Phone/Fax

Practice location:
  • Phone: 312-654-2721
  • Fax:
Mailing address:
  • Phone: 312-654-2720
  • Fax: 312-654-9930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036133704
License Number StateIL

VIII. Authorized Official

Name: AMITABHA MITRA
Title or Position: PRESIDENT
Credential:
Phone: 312-654-2720