Provider Demographics
NPI:1821034224
Name:DATTA SAMBARE M D S C
Entity Type:Organization
Organization Name:DATTA SAMBARE M D S C
Other - Org Name:MADISON PARKSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-379-2304
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:
Mailing Address - Fax:
Practice Address - Street 1:5650 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3939
Practice Address - Country:US
Practice Address - Phone:773-379-2304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DATTA SAMBARE M D S C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-22
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210064Medicare ID - Type Unspecified