Basic Information
| Provider Information | |||||||||
| NPI: | 1053428201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BEEN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8351 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761240351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6800 STATE ROUTE 162 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182885711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-116040 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2009030852 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | BS8825715 | 01 | DEA CERTIFICATE | OTHER | 036116040 7 | 05 | IL | MEDICAID | P00350429 | 01 | IL | RAILROAD MEDICARE | OTHER | 08232204 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036116040 | 05 | IL | MEDICAID | 08232205 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 06032182 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |