Basic Information
| Provider Information | |||||||||
| NPI: | 1003019647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULAMALLA | ||||||||
| FirstName: | SUMANTH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DESPLAINES ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606615500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 3126549930 | ||||||||
| Practice Location | |||||||||
| Address1: | 15900 W 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463113065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656333 | ||||||||
| FaxNumber: | 2193658291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01065980A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 201121060A | 05 | IN | MEDICAID | F400289465 | 01 | IL | IL MEDICARE PTAN | OTHER |