Provider Demographics
NPI:1316049166
Name:BALKRISHNA SUNDAR MD SC
Entity type:Organization
Organization Name:BALKRISHNA SUNDAR MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BALAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-692-6218
Mailing Address - Street 1:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-692-6218
Mailing Address - Fax:847-692-5609
Practice Address - Street 1:2674 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2361
Practice Address - Country:US
Practice Address - Phone:773-868-1800
Practice Address - Fax:773-868-4072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053086208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053086Medicaid
791342246OtherPALMETTO GBA
21609137OtherBC/BS
DH1341OtherPALMETTO GBA
IL636261Medicare PIN