Healthcare Provider Details

I. General information

NPI: 1013438795
Provider Name (Legal Business Name): ALEXANDRA LYNNE SURMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5758 S MARYLAND AVE
CHICAGO IL
60637-1426
US

IV. Provider business mailing address

1238 W HENDERSON ST APT 2
CHICAGO IL
60657-1499
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 616-826-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: