Healthcare Provider Details

I. General information

NPI: 1083069595
Provider Name (Legal Business Name): SANDERS PSYCHIATRIC ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2544 W MONTROSE AVE
CHICAGO IL
60618-1537
US

IV. Provider business mailing address

PO BOX 101281
CHICAGO IL
60610-8909
US

V. Phone/Fax

Practice location:
  • Phone: 773-267-2622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036087433
License Number StateIL

VIII. Authorized Official

Name: JERRY SANDERS
Title or Position: PRESIDENT
Credential: MD
Phone: 312-257-7771