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NPI Code Detail

MEDICARE: DR. SAMBASIVAM SUTHAN M.D

MEDICARE: DR. SAMBASIVAM SUTHAN M.D
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
1207R00000XInternal Medicine Physician059773GA
2207R00000XInternal Medicine Physician036126642IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1641203605AOTHERGAPEACHCARE FOR KIDS

General Provider Information

NPI Number : 1144413691
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SAMBASIVAM SUTHAN M.D
Provider Business Mailing Address
First Line : 12860 TROXLER AVE
Second Line :
City : HIGHLAND
State : IL
Zip : 62249-2898
Country : US
Telephone Number : 618-651-2810
Fax Number : 618-651-0077
Provider Business Practice Location Address
First Line : 12860 TROXLER AVE
Second Line :
City : HIGHLAND
State : IL
Zip : 62249-2898
Country : US
Telephone Number : 618-651-2810
Fax Number : 618-651-0077
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/18/2007
Last Update Date : 09/18/2024

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