Provider Demographics
NPI:1760698484
Name:CHANDER, THILAK (MD)
Entity Type:Individual
Prefix:DR
First Name:THILAK
Middle Name:
Last Name:CHANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1200
Mailing Address - Country:US
Mailing Address - Phone:906-635-9211
Mailing Address - Fax:906-635-9091
Practice Address - Street 1:511 ASHMUN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1960
Practice Address - Country:US
Practice Address - Phone:906-635-9090
Practice Address - Fax:906-635-9091
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068603207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104643831Medicaid
MI104643831Medicaid
MIN96930001Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID