Basic Information
| Provider Information | |||||||||
| NPI: | 1225065220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANDRA | ||||||||
| FirstName: | RAKESH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 396 LAKE INDIAN HILLS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182016996 | ||||||||
| FaxNumber: | 6189856860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1099 MEDICAL CENTER CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182016996 | ||||||||
| FaxNumber: | 6189981328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 37163 | KY | N | Behavioral Health & Social Service Providers | Psychologist | 2084P0800X | 036093240 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 370966854006 | 05 | IL | MEDICAID | 370966854011 | 05 | IL | MEDICAID | 64130982 | 05 | KY | MEDICAID | 036093240 | 05 | IL | MEDICAID | 370966854023 | 05 | IL | MEDICAID | 6413098200 | 05 | KY | MEDICAID | CF3444 | 01 | IL | MEDICARE RR | OTHER | P00830780 | 01 | KY | RR MEDICARE | OTHER | 370966854024 | 05 | IL | MEDICAID | P00464595 | 01 | KY | RR MEDICARE PIN # | OTHER |