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Organization
ROOSEVELT ROAD CLINIC MD SC
Active
Organization
ROOSEVELT ROAD CLINIC MD SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SUBARNA P PRADHAN M.D. (PRESIDENT)
(773) 638-6761
Entity
Organization
Contact information
Practice address
3600 W ROOSEVELT RD, CHICAGO, IL 60624-4225
(773) 638-6761
(773) 638-6984
Mailing address
3600 W ROOSEVELT RD, CHICAGO, IL 60624-4225
(773) 638-6761
(773) 638-6984
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036056560
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036056560
—
IL
01
—
636231
MEDICARE PTAN
IL
Enumeration date
04/12/2016
Last updated
04/12/2016
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