Provider Demographics
NPI:1508085762
Name:DR. GURIQBAL NANDRA
Entity Type:Organization
Organization Name:DR. GURIQBAL NANDRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-944-2929
Mailing Address - Street 1:845 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 930E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2252
Mailing Address - Country:US
Mailing Address - Phone:312-944-2929
Mailing Address - Fax:312-867-7841
Practice Address - Street 1:845 N MICHIGAN AVE
Practice Address - Street 2:SUITE 930E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2252
Practice Address - Country:US
Practice Address - Phone:312-944-2929
Practice Address - Fax:312-867-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG93394Medicare UPIN