Healthcare Provider Details

I. General information

NPI: 1740585736
Provider Name (Legal Business Name): CHANDRA B RATHOD MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 N CICERO AVE SUITE 203
CHICAGO IL
60641-1651
US

IV. Provider business mailing address

4211 N CICERO AVE SUITE 203
CHICAGO IL
60641-1650
US

V. Phone/Fax

Practice location:
  • Phone: 773-794-8800
  • Fax: 773-794-8830
Mailing address:
  • Phone: 773-794-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036059328
License Number StateIL

VIII. Authorized Official

Name: CHANDRA RATHOD
Title or Position: MDSC
Credential:
Phone: 773-793-8800