Healthcare Provider Details

I. General information

NPI: 1073726469
Provider Name (Legal Business Name): ANURADHA SUBRAMANIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD STE 204
FORT PIERCE FL
34950-4838
US

IV. Provider business mailing address

2402 FRIST BLVD STE 204
FORT PIERCE FL
34950-4838
US

V. Phone/Fax

Practice location:
  • Phone: 772-462-3939
  • Fax: 772-462-3938
Mailing address:
  • Phone: 772-462-3939
  • Fax: 772-462-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number056774
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number056774
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME132261
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: