Healthcare Provider Details

I. General information

NPI: 1699330811
Provider Name (Legal Business Name): SUJITHRA REPRAKASH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 TORRENCE AVE
CALUMET CITY IL
60409-1902
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-4100
  • Fax: 708-868-6910
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006364RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085006949
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: