Provider Demographics
NPI:1538656863
Name:CENTRAL CLINIC & RESEARCH SCIENCES INC
Entity Type:Organization
Organization Name:CENTRAL CLINIC & RESEARCH SCIENCES INC
Other - Org Name:CENTRAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MYSORE
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAGAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-275-7458
Mailing Address - Street 1:1224 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3300
Mailing Address - Country:US
Mailing Address - Phone:708-275-7458
Mailing Address - Fax:
Practice Address - Street 1:645 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-5059
Practice Address - Country:US
Practice Address - Phone:708-275-7458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty