Healthcare Provider Details

I. General information

NPI: 1407203805
Provider Name (Legal Business Name): NICHOLAS PAUL SURACI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date: 06/30/2021
Reactivation Date: 07/26/2021

III. Provider practice location address

4646 N MORINE DR DEPARTMENT OF ANESTHESIOLOGY
CHICAGO IL
60640
US

IV. Provider business mailing address

4646 N MORINE DR DEPARTMENT OF ANESTHESIOLOGY
CHICAGO IL
60640
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 773-878-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.075397
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.156359
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: