Provider Demographics
NPI:1114938263
Name:SIRAMDASU, SUGUNA (MD)
Entity Type:Individual
Prefix:
First Name:SUGUNA
Middle Name:
Last Name:SIRAMDASU
Suffix:
Gender:F
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:PO BOX 532904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2904
Mailing Address - Country:US
Mailing Address - Phone:217-443-5000
Mailing Address - Fax:
Practice Address - Street 1:812 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3752
Practice Address - Country:US
Practice Address - Phone:217-443-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061870207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36061870Medicaid
ILDA4244OtherRR MEDICARE GROUP
IL9232012OtherBCBS
IL50091711OtherRR MEDICARE
ILL98326Medicare PIN
IL9232012OtherBCBS
IL36061870Medicaid