Provider Demographics
NPI:1679571178
Name:SANE, PRAKASH (MD)
Entity type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:SANE
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17680 KEDZIE AVE
Practice Address - Street 2:201
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2043
Practice Address - Country:US
Practice Address - Phone:708-799-2499
Practice Address - Fax:708-799-4093
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047348Medicaid
ILC38466Medicare UPIN
ILK45495Medicare PIN
IL112910244Medicare PIN
ILK52818Medicare PIN