Healthcare Provider Details

I. General information

NPI: 1962501544
Provider Name (Legal Business Name): BANGARUSWAMY CHANDRAMOULI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S DAMEN AVE
CHICAGO IL
60612-3730
US

IV. Provider business mailing address

1521 FORDHAM CT
NAPERVILLE IL
60565-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6435
  • Fax:
Mailing address:
  • Phone: 630-778-1749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number18999
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: