1649285305 NPI number — DR. NIRMAL K SURTANI MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649285305 NPI number — DR. NIRMAL K SURTANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURTANI
Provider First Name:
NIRMAL
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649285305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 W BETHEL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47304-5407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-622-6575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2610 ENTERPRISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46013-9684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-683-4400
Provider Business Practice Location Address Fax Number:
765-213-3713
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  01040522A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200159310 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000087020 . This is a "ANTHEM PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200031677 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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