Provider Demographics
NPI:1285608315
Name:SULO, ROBERT M (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:SULO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21202 OWENS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2001
Mailing Address - Country:US
Mailing Address - Phone:779-334-0020
Mailing Address - Fax:779-334-0021
Practice Address - Street 1:21202 OWENS RD STE 201
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-2001
Practice Address - Country:US
Practice Address - Phone:779-334-0020
Practice Address - Fax:779-334-0021
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36064478207R00000X
IL036064478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36064478Medicaid
D15406Medicare UPIN
IL36064478Medicaid