Healthcare Provider Details

I. General information

NPI: 1073757571
Provider Name (Legal Business Name): KALYAN SANDESARA MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N WESTERN AVE
CHICAGO IL
60622-3565
US

IV. Provider business mailing address

2410 HALINA DR E
GLENVIEW IL
60026-1196
US

V. Phone/Fax

Practice location:
  • Phone: 773-342-3600
  • Fax: 773-342-4503
Mailing address:
  • Phone: 773-342-3600
  • Fax: 773-342-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036065899
License Number StateIL

VIII. Authorized Official

Name: KALYAN SANDESARA
Title or Position: PRESIDENT OF THE CORPORATION
Credential: M.D.
Phone: 773-342-3600