Provider Demographics
NPI:1427097104
Name:SUSSMAN, MITCHELL (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:SUSSMAN
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:RADIOLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-3270
Practice Address - Fax:217-383-4116
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360885372085R0202X
IL0360885372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088537*3Medicaid
IL0533210001OtherDMERC
IL036088537*3Medicaid
ILR00296Medicare PIN
ILIL3270396Medicare PIN