Healthcare Provider Details

I. General information

NPI: 1083604821
Provider Name (Legal Business Name): MICHAEL J SUTHERLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 650
CHICAGO IL
60611-2929
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 650
CHICAGO IL
60611-2929
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-4835
  • Fax: 312-695-3644
Mailing address:
  • Phone: 312-695-4835
  • Fax: 312-695-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number35132228
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number036160346
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35132228
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: