Healthcare Provider Details

I. General information

NPI: 1164724340
Provider Name (Legal Business Name): J SURANI PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 37TH ST STE B102
VERO BEACH FL
32960-4897
US

IV. Provider business mailing address

777 37TH ST STE B102
VERO BEACH FL
32960-4897
US

V. Phone/Fax

Practice location:
  • Phone: 772-569-3212
  • Fax: 772-569-1435
Mailing address:
  • Phone: 772-569-3212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME103068
License Number StateFL

VIII. Authorized Official

Name: PEGGIE CALAHAN
Title or Position: BILLING
Credential:
Phone: 772-569-3212