Provider Demographics
NPI:1790759835
Name:AHN, SUNG CHUL (DO)
Entity Type:Individual
Prefix:MR
First Name:SUNG
Middle Name:CHUL
Last Name:AHN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 GLENWOOD AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5474
Mailing Address - Country:US
Mailing Address - Phone:815-741-2201
Mailing Address - Fax:815-741-2285
Practice Address - Street 1:2400 GLENWOOD AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5474
Practice Address - Country:US
Practice Address - Phone:815-741-2201
Practice Address - Fax:815-741-2325
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36113220208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36113220Medicaid
IL36113220Medicaid
ILK16307Medicare ID - Type Unspecified
H40199Medicare UPIN