Provider Demographics
NPI:1215423843
Name:NAGALE, SOURABH (CPO)
Entity type:Individual
Prefix:
First Name:SOURABH
Middle Name:
Last Name:NAGALE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 N CLARK ST
Mailing Address - Street 2:STE 802
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-227-6210
Mailing Address - Fax:312-227-9429
Practice Address - Street 1:2515 N CLARK ST
Practice Address - Street 2:STE 802
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:312-227-6210
Practice Address - Fax:312-227-9429
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000186222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist