Basic Information
Provider Information | |||||||||
NPI: | 1790959872 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SC MOHAN MD SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 SAINT FRANCIS CIR | ||||||||
Address2: |   | ||||||||
City: | OAK BROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 605232559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7739899868 | ||||||||
FaxNumber: | 7737512250 | ||||||||
Practice Location | |||||||||
Address1: | 4755 N KENMORE AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606405015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7739899868 | ||||||||
FaxNumber: | 7737512250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2008 | ||||||||
LastUpdateDate: | 10/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOHAN | ||||||||
AuthorizedOfficialFirstName: | SANGARAPILLAI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7739899868 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036057255 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 036057255 | 05 | IL |   | MEDICAID |