Provider Demographics
NPI:1790233609
Name:RONNIE MANDAL DO, SC
Entity Type:Organization
Organization Name:RONNIE MANDAL DO, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:RANJAN
Authorized Official - Last Name:MANDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-757-5880
Mailing Address - Street 1:6634 N TRUMBULL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3738
Mailing Address - Country:US
Mailing Address - Phone:847-757-5880
Mailing Address - Fax:
Practice Address - Street 1:2740 W FOSTER AVE STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3547
Practice Address - Country:US
Practice Address - Phone:773-545-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
IL036119779282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty