=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750461760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANGARAPILLAI CHONDRA MOHAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 10/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4755 N KENMORE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-989-9868
-----------------------------------------------------
Fax | 773-989-9824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 SAINT FRANCIS CIR
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-989-9868
-----------------------------------------------------
Fax | 773-989-9824
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036057255
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------