Provider Demographics
NPI:1740585736
Name:CHANDRA B RATHOD MDSC
Entity Type:Organization
Organization Name:CHANDRA B RATHOD MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDSC
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RATHOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-793-8800
Mailing Address - Street 1:4211 N CICERO AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1650
Mailing Address - Country:US
Mailing Address - Phone:773-794-8800
Mailing Address - Fax:
Practice Address - Street 1:4211 N CICERO AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1651
Practice Address - Country:US
Practice Address - Phone:773-794-8800
Practice Address - Fax:773-794-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059328261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care