Provider Demographics
NPI:1891895819
Name:SUNDARAM, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:SUNDARAM
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 1:2550 MOSSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3540
Mailing Address - Country:US
Mailing Address - Phone:412-457-1100
Mailing Address - Fax:412-457-0250
Practice Address - Street 1:2550 MOSSIDE BLVD
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146
Practice Address - Country:US
Practice Address - Phone:412-457-1100
Practice Address - Fax:412-457-0250
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068955L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001757848Medicaid
PA1971654OtherFIRST HEALTH/COVENTRY
PAP002009OtherGATEWAY
PA597886OtherBLUE SHIELD
PA14659OtherBRAVO
PA17578480003Medicaid
PA597886OtherBLUE SHIELD
PA028420V38Medicare PIN