Provider Demographics
NPI:1073527743
Name:SUNDARAM, MECHERI (MD)
Entity Type:Individual
Prefix:DR
First Name:MECHERI
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500N STATE ST
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5500
Practice Address - Fax:601-984-5499
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS137132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0112950Medicaid
MSP00620822OtherRAILROAD MEDICARE
MS0112950Medicaid
MSP01198358Medicare PIN
MS512I130005Medicare PIN
MSP00620822OtherRAILROAD MEDICARE
MS302I137030Medicare PIN