Healthcare Provider Details

I. General information

NPI: 1922014315
Provider Name (Legal Business Name): VISWANATHAM SUSARLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 SUMMIT ST STE 123
ELGIN IL
60120-5145
US

IV. Provider business mailing address

860 SUMMIT ST STE 123
ELGIN IL
60120-5145
US

V. Phone/Fax

Practice location:
  • Phone: 847-741-0026
  • Fax: 847-741-0027
Mailing address:
  • Phone: 847-741-0026
  • Fax: 847-741-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036047106
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036047106
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: