Healthcare Provider Details

I. General information

NPI: 1356802201
Provider Name (Legal Business Name): PHANI KEERTHI SURAPANENI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 PIERCE ST STE 414
SIOUX CITY IA
51104-3755
US

IV. Provider business mailing address

2800 PIERCE ST STE 414
SIOUX CITY IA
51104-3755
US

V. Phone/Fax

Practice location:
  • Phone: 712-220-6634
  • Fax: 712-220-6640
Mailing address:
  • Phone: 712-220-6634
  • Fax: 712-220-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-51150
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberMD-51150
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: