Basic Information
| Provider Information | |||||||||
| NPI: | 1679569172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTYAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19663 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175457795 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 N RUTLEDGE ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627026700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175455183 | ||||||||
| FaxNumber: | 2175457795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036-104455 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 036-104455 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 036104455 | 05 | IL | MEDICAID |