Basic Information
| Provider Information | |||||||||
| NPI: | 1841217551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUNDAR | ||||||||
| FirstName: | BALAKRISHNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600683141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476926218 | ||||||||
| FaxNumber: | 8476925609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 ORO DAM BLVD E | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959666052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307122171 | ||||||||
| FaxNumber: | 5307122149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036053086 | IL | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | C153404 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 791342246 | 01 | PALMETTO GBA | OTHER | 036053086 | 01 | IL | STATE LICENSE | OTHER | 21609137 | 01 | BLUE SHIELD | OTHER | 036053086 | 05 | IL | MEDICAID |