Provider Demographics
NPI:1124067863
Name:LAL, SURENDER (MD)
Entity type:Individual
Prefix:
First Name:SURENDER
Middle Name:
Last Name:LAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 S KEDZIE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652
Mailing Address - Country:US
Mailing Address - Phone:773-434-2123
Mailing Address - Fax:773-434-3146
Practice Address - Street 1:7722 S KEDZIE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652
Practice Address - Country:US
Practice Address - Phone:773-434-2123
Practice Address - Fax:773-434-3146
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31601156OtherBC
IL036057513Medicaid
734350Medicare ID - Type Unspecified
IL036057513Medicaid