Basic Information
Provider Information | |||||||||
NPI: | 1265429419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOPPANA | ||||||||
FirstName: | SURESH | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 703 VOLKER HL | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352940001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059343795 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1600 7TH AVE S | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352331711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059399587 | ||||||||
FaxNumber: | 2059754623 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2005 | ||||||||
LastUpdateDate: | 01/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.15386 | AL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 208000000X | MD.15386 | AL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 009912612 | 05 | AL |   | MEDICAID | 009930750 | 05 | AL |   | MEDICAID | 4461381 | 01 | AL | AETNA | OTHER | 510-95531 | 01 | AL | BCBS | OTHER | 1265429419 | 01 | AL | TRICARE SOUTH | OTHER | 000088303 | 05 | AL |   | MEDICAID | 510-88303 | 01 | AL | BCBS | OTHER |