=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841501608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P. DEGAND M D SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2010
-----------------------------------------------------
Last Update Date | 04/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2555 S MARTIN LUTHER KING DR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-842-3971
-----------------------------------------------------
Fax | 312-842-3691
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2555 S MARTIN LUTHER KING DR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-842-3971
-----------------------------------------------------
Fax | 312-842-3691
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PANCHO DEGAND
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 312-842-3971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036055665
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------