Healthcare Provider Details

I. General information

NPI: 1295050821
Provider Name (Legal Business Name): BALA KANAGARAJU, M.D.S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7914 S ASHLAND AVE
CHICAGO IL
60620-4335
US

IV. Provider business mailing address

1807 VOLLMER RD
FLOSSMOOR IL
60422-1960
US

V. Phone/Fax

Practice location:
  • Phone: 773-651-6800
  • Fax:
Mailing address:
  • Phone: 708-799-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BALA R KANAGARAJU
Title or Position: OWNER
Credential: M.D
Phone: 708-799-0234