Basic Information
| Provider Information | |||||||||
| NPI: | 1548670417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHARDWAJ | ||||||||
| FirstName: | SURUCHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342951000 | ||||||||
| FaxNumber: | 4349724266 | ||||||||
| Practice Location | |||||||||
| Address1: | 2955 IVY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245485 | ||||||||
| FaxNumber: | 4342434784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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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 | 207W00000X | 0101264189 | VA | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | MT205765 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1548670417 | 05 | VA | MEDICAID |