Basic Information
| Provider Information | |||||||||
| NPI: | 1740433291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOPANNA | ||||||||
| FirstName: | SURAJ | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD, MRCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
| FaxNumber: | 7796967342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796966102 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 40265 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 40265 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 036-126456 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 40265 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 036-126456 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.