Provider Demographics
NPI:1376582999
Name:NAIR, SUDEEP (MD)
Entity Type:Individual
Prefix:
First Name:SUDEEP
Middle Name:
Last Name:NAIR
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 1:602 S 42ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6264
Mailing Address - Country:US
Mailing Address - Phone:618-899-3777
Mailing Address - Fax:618-242-2378
Practice Address - Street 1:602 S 42ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6264
Practice Address - Country:US
Practice Address - Phone:618-899-3777
Practice Address - Fax:618-242-2378
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCK7203OtherRR GROUP NUMBER
IL110143249OtherRR MEDICARE
IL036092998Medicaid
IL04108653OtherBCBS
ILK40265Medicare PIN
IL036092998Medicaid
IL247150Medicare ID - Type UnspecifiedMED