MEDICARE: DR. PAUL R. SANDERS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071002781	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001672882	OTHER	IL	BLUE CROSS PROVIDER NUMBE
2	363522880	OTHER	IL	FEDERAL TAX I.D. NUMBER
3	071002781	OTHER	IL	PROFESSIONAL LICENSE

General Provider Information

NPI Number	:	1700893237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL R. SANDERS PH.D.

Provider Business Mailing Address
First Line	:	3647 RADCLIFFE DR
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-4215
Country	:	US
Telephone Number	:	847-302-7682
Fax Number	:	312-277-5360

Provider Business Practice Location Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	SUITE 1704
City	:	CHICAGO
State	:	IL
Zip	:	60602-3402
Country	:	US
Telephone Number	:	312-332-6091
Fax Number	:	312-332-6508

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	09/09/2020

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