Provider Demographics
NPI:1851034946
Name:SUTHERLIN, MATHIS
Entity Type:Individual
Prefix:MR
First Name:MATHIS
Middle Name:
Last Name:SUTHERLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 S CHAMPLAIN AVE # 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6611 S CHAMPLAIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-4101
Practice Address - Country:US
Practice Address - Phone:312-709-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS36454084348172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver