Healthcare Provider Details

I. General information

NPI: 1497047641
Provider Name (Legal Business Name): SUNDARAM KRISHNAN CHETTIAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 WILKENS AVE STE 300
BALTIMORE MD
21229-5218
US

IV. Provider business mailing address

3449 WILKENS AVE STE 107
BALTIMORE MD
21229-5216
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-2922
  • Fax: 667-234-9997
Mailing address:
  • Phone: 667-234-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberD79893
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: