Basic Information
Provider Information | |||||||||
NPI: | 1417690876 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BISWAS | ||||||||
FirstName: | SUDAKSHINA | ||||||||
MiddleName: | NONE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BISWAS | ||||||||
OtherFirstName: | SHEENA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 904 BAYBROOK CT | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 616151065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3099920593 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8600 ILLINOIS ROUTE-91, SUITE 130 OSF INTERNAL MED | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 61615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096835050 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2022 | ||||||||
LastUpdateDate: | 04/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 209022858 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.