Provider Demographics
NPI:1023683513
Name:CORNELIA V. TANDEZ,MD,LTD
Entity type:Organization
Organization Name:CORNELIA V. TANDEZ,MD,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-962-0149
Mailing Address - Street 1:8248 W BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1544
Mailing Address - Country:US
Mailing Address - Phone:847-962-0149
Mailing Address - Fax:
Practice Address - Street 1:637 E GOLF RD STE 209
Practice Address - Street 2:
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4070
Practice Address - Country:US
Practice Address - Phone:847-258-5098
Practice Address - Fax:847-258-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086199Medicaid