MEDICARE: JOHN R SUTTER M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35-06-6614-S	OH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	080065425	OTHER	OH	RR MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000013688	OTHER	OH	ANTHEM
2	0122536	OTHER	OH	UNITED HEALTH CARE
3	4484969	OTHER	OH	AETNA
4	311202780009	OTHER	OH	CIGNA
6	OH0000444	OTHER	OH	TRICARE/CHAMPUS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1710980685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R SUTTER M.D.

Provider Business Mailing Address
First Line	:	3250 MIDDLE URBANA RD
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45502-9285
Country	:	US
Telephone Number	:	937-399-7777
Fax Number	:	937-399-6794

Provider Business Practice Location Address
First Line	:	3250 MIDDLE URBANA RD
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45502-9285
Country	:	US
Telephone Number	:	937-399-7777
Fax Number	:	937-399-6794

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/18/2020

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039

3250 MIDDLE URBANA RD
SPRINGFIELD, OH
45502-9285