Provider Demographics
NPI:1730593823
Name:MANAPURAM, SURESH (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:MANAPURAM
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 1:2620 W FAIDLEY AVE
Mailing Address - Street 2:DEPT OF HOSPITAL MEDICINE
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803
Mailing Address - Country:US
Mailing Address - Phone:412-713-2191
Mailing Address - Fax:
Practice Address - Street 1:2620 W FAIDLEY AVE
Practice Address - Street 2:DEPT OF HOSPITAL MEDICINE
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803
Practice Address - Country:US
Practice Address - Phone:412-713-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30750207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE30750OtherNEBRASKA MEDICAL LICENSE NUMBER