Provider Demographics
NPI:1114094281
Name:RAJIV KANDALA M D S C
Entity Type:Organization
Organization Name:RAJIV KANDALA M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-793-4527
Mailing Address - Street 1:1720 S MICHIGAN AVE APT 2909
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4861
Mailing Address - Country:US
Mailing Address - Phone:630-405-5500
Mailing Address - Fax:708-226-5690
Practice Address - Street 1:7531 S STONY ISLAND
Practice Address - Street 2:#152
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649
Practice Address - Country:US
Practice Address - Phone:773-947-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109208Medicaid
BK8290188OtherDEA
H88810Medicare UPIN