Provider Demographics
NPI:1477652444
Name:SANTILUKKA, PICHET (MD)
Entity Type:Individual
Prefix:DR
First Name:PICHET
Middle Name:
Last Name:SANTILUKKA
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:PO BOX 168
Mailing Address - Street 2:415 W S FOURTH STREET SUITE A
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-0168
Mailing Address - Country:US
Mailing Address - Phone:618-282-3883
Mailing Address - Fax:618-282-6133
Practice Address - Street 1:415 W S FOURTH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-0168
Practice Address - Country:US
Practice Address - Phone:618-282-3883
Practice Address - Fax:618-282-6133
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3646325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417058777OtherNPI -- GROUP
IL036046325Medicaid
IL036046325Medicaid
C38891Medicare UPIN