Basic Information
| Provider Information | |||||||||
| NPI: | 1598857716 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANG H SUH, M.D. S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W 79TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844523 | ||||||||
| FaxNumber: | 7738844580 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605163603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309647382 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | SUH | ||||||||
| AuthorizedOfficialFirstName: | SANG | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6309647382 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. S.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036055218 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036055218 | 05 | IL | MEDICAID |