Provider Demographics
NPI:1871921999
Name:SUBURBAN WELLNESS SC
Entity type:Organization
Organization Name:SUBURBAN WELLNESS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDARSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKRABARTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-737-7136
Mailing Address - Street 1:113 CIRCLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8380
Mailing Address - Country:US
Mailing Address - Phone:708-737-7136
Mailing Address - Fax:
Practice Address - Street 1:15750 S BELL RD STE 2D
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8420
Practice Address - Country:US
Practice Address - Phone:708-737-7136
Practice Address - Fax:708-887-5886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty