Provider Demographics
NPI:1790115517
Name:DATTA SAMBARE MD SC
Entity Type:Organization
Organization Name:DATTA SAMBARE MD SC
Other - Org Name:NORTH FOREST MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-613-4738
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-0215
Mailing Address - Country:US
Mailing Address - Phone:708-613-4738
Mailing Address - Fax:
Practice Address - Street 1:6957 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1068
Practice Address - Country:US
Practice Address - Phone:708-613-4738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DATTA.SAMBARE.MD,SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-14
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129147261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care