Provider Demographics
NPI:1174572119
Name:SUMIDA, COLIN W (MD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:W
Last Name:SUMIDA
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 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD STE 240
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9528
Practice Address - Country:US
Practice Address - Phone:815-740-1900
Practice Address - Fax:815-485-4463
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065985207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065985Medicaid
ILL94313Medicare PIN
ILE85261Medicare UPIN
IL036065985Medicaid
ILL55721Medicare PIN
ILK18684Medicare PIN