Healthcare Provider Details

I. General information

NPI: 1992756837
Provider Name (Legal Business Name): ALEKSANDR SUROVETS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 PEACHTREE DUNWOODY RD NE SUITE 150
ATLANTA GA
30342-1764
US

IV. Provider business mailing address

PO BOX 70547
MARIETTA GA
30007-0547
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-6104
  • Fax:
Mailing address:
  • Phone: 770-579-1894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004747
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number004747
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: