Healthcare Provider Details

I. General information

NPI: 1740433291
Provider Name (Legal Business Name): SURAJ BOPANNA MD, MRCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-6102
  • Fax:
Mailing address:
  • Phone: 779-696-7150
  • Fax: 779-696-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number1261-320
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036-126456
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number40265
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number40265
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036-126456
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40265
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number1261-320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: