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General NPI Number Information
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NPI Number | 1073757571
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Entity Type | Organization
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Legal Business Name | KALYAN SANDESARA MD SC
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Dates
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Enumeration Date | 04/28/2009
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Last Update Date | 04/28/2009
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Provider Practice Location Address
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Address Line | 1008 N WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60622-3565
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Country | US
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Telephone | 773-342-3600
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Fax | 773-342-4503
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Provider Business Mailing Address
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Address Line | 2410 HALINA DR E
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City | GLENVIEW
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State | IL
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Zip | 60026-1196
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Country | US
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Telephone | 773-342-3600
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Fax | 773-342-4503
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Authorized Official
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Title or Position | PRESIDENT OF THE CORPORATION
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Name | KALYAN SANDESARA
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Credential | M.D.
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Telephone | 773-342-3600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036065899
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License Number State | IL
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