Provider Demographics
NPI:1144204793
Name:SANKARAN, SURYA (MD)
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:SANKARAN
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 1:4449 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5217
Mailing Address - Country:US
Mailing Address - Phone:989-790-0007
Mailing Address - Fax:989-790-7547
Practice Address - Street 1:651 M 55 E
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9238
Practice Address - Country:US
Practice Address - Phone:989-362-8681
Practice Address - Fax:989-362-3321
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA76915Medicare UPIN
MI0359729Medicare ID - Type Unspecified
MI1402164Medicare ID - Type Unspecified