Healthcare Provider Details

I. General information

NPI: 1124012901
Provider Name (Legal Business Name): ROBERT W MANDAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N RANDALL RD 300
ELGIN IL
60123-9400
US

IV. Provider business mailing address

25070 NETWORK PL
CHICAGO IL
60673-1250
US

V. Phone/Fax

Practice location:
  • Phone: 847-931-0909
  • Fax: 847-488-9596
Mailing address:
  • Phone: 847-585-7000
  • Fax: 847-240-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036095612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: