Provider Demographics
NPI:1124173273
Name:SUJATHA RAO M.D., P.C.
Entity type:Organization
Organization Name:SUJATHA RAO M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUJATHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-529-0120
Mailing Address - Street 1:3255 CINNEBAR PT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5203
Mailing Address - Country:US
Mailing Address - Phone:618-529-0120
Mailing Address - Fax:
Practice Address - Street 1:1390 HOPE DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5306
Practice Address - Country:US
Practice Address - Phone:618-529-0120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111928207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03932030OtherBLUE CROSS BLUE SHIELD IL
IL036111928Medicaid
IL036111928Medicaid
IL036111928Medicaid
IL=========OtherTRICARE
IL6621450001Medicare NSC