Provider Demographics
NPI:1841501608
Name:P. DEGAND M D SC
Entity type:Organization
Organization Name:P. DEGAND M D SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PANCHO
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-842-3971
Mailing Address - Street 1:2555 S MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2419
Mailing Address - Country:US
Mailing Address - Phone:312-842-3971
Mailing Address - Fax:312-842-3691
Practice Address - Street 1:2555 S MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2419
Practice Address - Country:US
Practice Address - Phone:312-842-3971
Practice Address - Fax:312-842-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-27
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055665207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty