Provider Demographics
NPI:1801838651
Name:NALLANI, SURYA (MD)
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:NALLANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 ROTHWELL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1577
Mailing Address - Country:US
Mailing Address - Phone:248-935-8103
Mailing Address - Fax:734-338-8301
Practice Address - Street 1:1229 ROTHWELL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-935-8103
Practice Address - Fax:734-338-8301
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108115181OtherBCBSM
MI1821196551OtherCOMMERCIAL
MI104797195Medicaid
MI23D1049104OtherCLIA
MI1108115181OtherBCBSM
MI104797195Medicaid