Basic Information
| Provider Information | |||||||||
| NPI: | 1801838651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NALLANI | ||||||||
| FirstName: | SURYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1229 ROTHWELL DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489358103 | ||||||||
| FaxNumber: | 7343388301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1229 ROTHWELL DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489358103 | ||||||||
| FaxNumber: | 7343388301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301073842 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1108115181 | 01 | MI | BCBSM | OTHER | 1821196551 | 01 | MI | COMMERCIAL | OTHER | 104797195 | 05 | MI | MEDICAID | 23D1049104 | 01 | MI | CLIA | OTHER |