Provider Demographics
NPI:1033231675
Name:KANU PANCHAL MDSC
Entity Type:Organization
Organization Name:KANU PANCHAL MDSC
Other - Org Name:NEURO SPINE CENTER OF NORTHERN ILLINOIS SC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KANU
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-344-0175
Mailing Address - Street 1:4309 W MEDICAL CENTER DR
Mailing Address - Street 2:SUITE B301
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8419
Mailing Address - Country:US
Mailing Address - Phone:815-344-0175
Mailing Address - Fax:815-344-0145
Practice Address - Street 1:4309 W MEDICAL CENTER DR
Practice Address - Street 2:SUITE B301
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8419
Practice Address - Country:US
Practice Address - Phone:815-344-0175
Practice Address - Fax:815-344-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21609919OtherBLUE CROSS BLUE SHIELD
ILC43122Medicare UPIN
IL684392Medicare ID - Type Unspecified