Provider Demographics
NPI:1144413691
Name:SUTHAN, SAMBASIVAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMBASIVAM
Middle Name:
Last Name:SUTHAN
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 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-463-5905
Mailing Address - Fax:618-463-5935
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-5905
Practice Address - Fax:618-463-5935
Is Sole Proprietor?:No
Enumeration Date:2007-08-18
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059773207R00000X
IL036126642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA641203605AOtherPEACHCARE FOR KIDS
GA641203605AOtherPEACHCARE FOR KIDS