Basic Information
| Provider Information | |||||||||
| NPI: | 1679568687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUKHUM | ||||||||
| FirstName: | PRADUB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 20098 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 6D091SU | 01 | BLUE CROSS BLUE SHIELD | OTHER | 600816 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 2114056 | 01 | FIRST HEALTH PLAN | OTHER | 2528849 | 01 | MEDICA HEALTH PLANS | OTHER | 986029 | 01 | PREFERRED ONE | OTHER | 109310 | 01 | UCARE | OTHER | HP25524 | 01 | HEALTH PARTNERS | OTHER |