Healthcare Provider Details

I. General information

NPI: 1730758533
Provider Name (Legal Business Name): ANISH SURAPANENI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 AUSTELL RD
AUSTELL GA
30106-1844
US

IV. Provider business mailing address

4444 AUSTELL RD
AUSTELL GA
30106-1844
US

V. Phone/Fax

Practice location:
  • Phone: 678-460-2700
  • Fax:
Mailing address:
  • Phone: 678-460-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number110811
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: