Healthcare Provider Details

I. General information

NPI: 1689948770
Provider Name (Legal Business Name): SEAN SUTPHEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 WAUKEGAN RD STE 110
BANNOCKBURN IL
60015
US

IV. Provider business mailing address

900 RAND RD STE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 847-914-9096
  • Fax: 847-914-9009
Mailing address:
  • Phone: 847-324-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036146136
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: