Provider Demographics
NPI:1053350173
Name:SUN, GEORGE (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:SUN
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 1:430 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3006
Mailing Address - Country:US
Mailing Address - Phone:618-436-8350
Mailing Address - Fax:618-532-9347
Practice Address - Street 1:430 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-436-8350
Practice Address - Fax:618-532-9347
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207988OtherGROUP
ILCH4443OtherRR GROUP NUMBER
ILP00180554OtherRR MEDICARE NUMBER
IL207988OtherGROUP
ILC45599Medicare UPIN