Basic Information
| Provider Information | |||||||||
| NPI: | 1174822415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THANAM | ||||||||
| FirstName: | SUSRUTHA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | AUSTIN STATE HOSPITAL | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124192148 | ||||||||
| FaxNumber: | 5124192163 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | AUSTIN STATE HOSPITAL | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124192148 | ||||||||
| FaxNumber: | 5124192163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Q2860 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.