1316049166 NPI number — BALKRISHNA SUNDAR MD SC

Table of content: (NPI 1316049166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316049166 NPI number — BALKRISHNA SUNDAR MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALKRISHNA SUNDAR MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKESHORE UROLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316049166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 798
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARK RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-692-6218
Provider Business Mailing Address Fax Number:
847-692-5609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2674 N HALSTED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-868-1800
Provider Business Practice Location Address Fax Number:
773-868-4072
Provider Enumeration Date:
09/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUNDAR
Authorized Official First Name:
BALAKRISHNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-692-6218

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  036053086 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036053086 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 791342246 . This is a "PALMETTO GBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21609137 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DH1341 . This is a "PALMETTO GBA" identifier . This identifiers is of the category "OTHER".