Provider Demographics
NPI:1861499675
Name:SURTI, GHULAM MUSTAFA (MD)
Entity type:Individual
Prefix:
First Name:GHULAM
Middle Name:MUSTAFA
Last Name:SURTI
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 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6200
Mailing Address - Fax:401-455-6309
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6200
Practice Address - Fax:401-455-6309
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD099372084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02246624Medicaid
RI1104801349OtherBUTLER HOSPITAL NPI
RI406629OtherBLUE CHIP
RIGS29847Medicaid
RIP00362436OtherMEDICARE RAILROAD
RI007008181OtherMEDICARE ID-TYPE UNSPECIFIED
RI1093831646OtherBUTLER HOSPITAL PROFESSIONAL BILLING OFFICE
RI15-43150OtherUNITED BEHAVIORAL HEALTH
RI23998-5OtherBLUE CROSS
RI15-43150OtherUNITED BEHAVIORAL HEALTH
RI007056957Medicare ID - Type Unspecified