MEDICARE: RIA SUMITRO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1043161359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RIA SUMITRO

Provider Business Mailing Address
First Line	:	3210 COUNTRYBEND LN
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-6154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 COUNTRYBEND LN
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-6154
Country	:	US
Telephone Number	:	217-417-7518
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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Directions to “ RIA SUMITRO ” Practice Location

Language	Start Address	Practice Location

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