Provider Demographics
NPI:1821294141
Name:PITU G PUNJABI MD SC
Entity Type:Organization
Organization Name:PITU G PUNJABI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PITU
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUNJABI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-767-0100
Mailing Address - Street 1:6084 S ARCHER AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2747
Mailing Address - Country:US
Mailing Address - Phone:773-767-0100
Mailing Address - Fax:773-767-9690
Practice Address - Street 1:6084 S ARCHER AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2747
Practice Address - Country:US
Practice Address - Phone:773-767-0100
Practice Address - Fax:773-767-9690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-24
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2201598OtherBLUE CROSS BLUE SHIELD OF
IL036053482Medicaid
IL110019865OtherRAIL ROAD MEDICARE
IL036053482Medicaid
IL036053482Medicaid