MEDICARE: DR. SUNDARA K MANICKAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35074669	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548234321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUNDARA K MANICKAM MD

Provider Business Mailing Address
First Line	:	5334 MEADOW LANE CT
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44035-1469
Country	:	US
Telephone Number	:	440-934-8921
Fax Number	:	440-934-8938

Provider Business Practice Location Address
First Line	:	5334 MEADOW LANE CT
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44035-1469
Country	:	US
Telephone Number	:	440-934-8921
Fax Number	:	440-934-8938

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	04/22/2010

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