Basic Information
| Provider Information | |||||||||
| NPI: | 1710936984 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MIN | ||||||||
| FirstName: | SUN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MACARTHUR BOULEVARD | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198367040 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01051876A | IN | N | Other Service Providers | Specialist | 207L00000X | 01051876A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036094917 | 05 | IL | MEDICAID | 000000081316 | 01 | IN | ANTHEM BCBS | OTHER | 200244830A | 05 | IN | MEDICAID |