Provider Demographics
NPI:1437137478
Name:SUNDRAM, PONNAMBALAM S (MD)
Entity type:Individual
Prefix:
First Name:PONNAMBALAM
Middle Name:S
Last Name:SUNDRAM
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 1:71 W 156TH ST
Mailing Address - Street 2:STE 305
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-4260
Mailing Address - Country:US
Mailing Address - Phone:708-331-2200
Mailing Address - Fax:708-331-8015
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:STE 305
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-331-2200
Practice Address - Fax:708-331-8015
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070565207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360705655Medicaid
IL060058942OtherPALMETTO RR MEDICARE
IL0360705655Medicaid
ILPINL77266Medicare ID - Type Unspecified