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12860 Troxler Avenue Highland IL 62249-2806 | |
| (618) 651-2810 | |
| (618) 651-0077 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 12860 Troxler Avenue, Highland, Illinois |
| Authorized Official Name and Position | Andrew Watson (CFO) |
| Authorized Official Contact | 2174925806 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
12860 Troxler Avenue Highland IL 62249-2806 Ph: (618) 651-2810 | 12860 Troxler Avenue Highland IL 62249-2806 Ph: (618) 651-2810 |
| NPI Number | 1851536296 |
|---|---|
| Provider Enumeration Date | 12/15/2008 |
| Last Update Date | 08/17/2022 |
| Medicare PECOS PAC ID | 5092857821 |
|---|---|
| Medicare Enrollment ID | O20110304000395 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851536296 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | 036111703 (Illinois) | Primary |
| Provider Name | Sambasivam Suthan |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1144413691 PECOS PAC ID: 2567558661 Enrollment ID: I20110223000864 |
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