Healthcare Provider Details

I. General information

NPI: 1174740435
Provider Name (Legal Business Name): SANDEEP CHUNDURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E CONGRESS PKWY SUITE 300
CRYSTAL LAKE IL
60014-6245
US

IV. Provider business mailing address

525 E CONGRESS PKWY STE 300
CRYSTAL LAKE IL
60014-6258
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-9260
  • Fax: 815-459-7460
Mailing address:
  • Phone: 815-759-9260
  • Fax: 815-459-7840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number36110541
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: