Healthcare Provider Details

I. General information

NPI: 1275542912
Provider Name (Legal Business Name): SUMUK SUNDARAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 WINDSOR RD
CHAMPAIGN IL
61822-6217
US

IV. Provider business mailing address

1801 WINDSOR RD
CHAMPAIGN IL
61822-6217
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-5434
  • Fax:
Mailing address:
  • Phone: 217-366-5434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-101030
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-101030
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier279500
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerMEDICARE GROUP
# 2
Identifier110211234
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier1275542912 1
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: