Provider Demographics
NPI:1790742195
Name:SUBODH C DESAI MD SC
Entity Type:Organization
Organization Name:SUBODH C DESAI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-827-7000
Mailing Address - Street 1:2137 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1718
Mailing Address - Country:US
Mailing Address - Phone:708-746-4660
Mailing Address - Fax:708-749-4665
Practice Address - Street 1:2137 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1718
Practice Address - Country:US
Practice Address - Phone:708-746-4660
Practice Address - Fax:708-749-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207004Medicare ID - Type Unspecified