Provider Demographics
NPI:1750643748
Name:SANGCHANTR MEDICAL ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:SANGCHANTR MEDICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WANCHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGCHANTR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-665-3084
Mailing Address - Street 1:4207 RUTGERS LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2913
Mailing Address - Country:US
Mailing Address - Phone:773-348-7305
Mailing Address - Fax:773-665-3012
Practice Address - Street 1:2900 N LAKE SHORE DR
Practice Address - Street 2:GI LAB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5640
Practice Address - Country:US
Practice Address - Phone:773-665-3084
Practice Address - Fax:773-665-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-046323207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38643Medicare UPIN