Healthcare Provider Details

I. General information

NPI: 1750374807
Provider Name (Legal Business Name): SUZANNE R TRUPIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 S NEIL ST
CHAMPAIGN IL
61820-7266
US

IV. Provider business mailing address

2109 S NEIL ST
CHAMPAIGN IL
61820-7266
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-3736
  • Fax: 217-953-0885
Mailing address:
  • Phone: 217-356-3736
  • Fax: 217-953-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036062169
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: