Provider Demographics
NPI:1861473936
Name:KAILAS, SUJATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJATHA
Middle Name:
Last Name:KAILAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5744 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4302
Mailing Address - Country:US
Mailing Address - Phone:312-335-0180
Mailing Address - Fax:773-275-4679
Practice Address - Street 1:5744 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4302
Practice Address - Country:US
Practice Address - Phone:312-335-0180
Practice Address - Fax:773-275-4679
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30129207RG0100X
IL036.134009207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31576500Medicaid
WI110114149OtherRAILROAD MEDICARE
ILF400429459OtherMEDICARE
WI31576500Medicaid
WI30129OtherTOUCHPOINT
E49060Medicare UPIN