Provider Demographics
NPI:1205814100
Name:SATTAYATAM, PRICHA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRICHA
Middle Name:
Last Name:SATTAYATAM
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 1:5204 DIXON DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 E TREMONT ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1912
Practice Address - Country:US
Practice Address - Phone:217-532-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048608207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048608Medicaid
IL036048608Medicaid
ILK25530Medicare PIN