Provider Demographics
NPI:1093975419
Name:GRANDHI, SANDHYA RANI
Entity Type:Individual
Prefix:
First Name:SANDHYA
Middle Name:RANI
Last Name:GRANDHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 E MAIN ST
Mailing Address - Street 2:P O BOX 3988
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3114
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-457-4542
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125834Medicaid
LA00022Medicaid
IL036125834Medicaid
IL214771Medicare Oscar/Certification