Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 036087174 | IL |
NPI | 1790705663 |
---|---|
Provider Name | Sangili Chandran |
First Address | Hometown, IL 60456-1135 |
Second Address | Hometown, IL 60456-1135 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2006 |
Last Update Date | 15/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
#036087174 | (05) | IL |
G14912 | (02) |