Basic Information
| Provider Information | |||||||||
| NPI: | 1578583357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENKAR | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | JAGANNATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 KIMEL PARK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 KIMEL PARK DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20678 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1373R | 01 | NC | BCBS | OTHER | P00184454 | 01 | NC | RR MEDICARE | OTHER | 8966745 | 05 | NC | MEDICAID |