Basic Information
| Provider Information | |||||||||
| NPI: | 1447369293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTKOWSKI | ||||||||
| FirstName: | MARYBETH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1870 W GALENA BLVD | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605064356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308596700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1870 W GALENA BLVD | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605064356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308596700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-089686 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036089686 | 05 | IL | MEDICAID |