Provider Demographics
NPI:1902986730
Name:SUPPIAH, PALANIAPPAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PALANIAPPAN
Middle Name:
Last Name:SUPPIAH
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 1:1201 RICKER RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-4263
Mailing Address - Country:US
Mailing Address - Phone:618-548-3194
Mailing Address - Fax:618-548-6800
Practice Address - Street 1:1321 W WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2013
Practice Address - Country:US
Practice Address - Phone:618-548-0466
Practice Address - Fax:618-548-4512
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062337Medicaid
IL036062337Medicaid
C44969Medicare UPIN
IL673300Medicare PIN
ILAS1187106OtherFEDERAL DEA