Provider Demographics
NPI:1972684959
Name:SUNDARAM, BASKARAN (MB, BS)
Entity Type:Individual
Prefix:DR
First Name:BASKARAN
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:M
Credentials:MB, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:SUITE 3390
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:SUITE 3390
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-6226
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010810712085R0202X
PAMD4504832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4507375Medicaid
MIH86010Medicare UPIN
MI4507375Medicaid