Healthcare Provider Details

I. General information

NPI: 1124009287
Provider Name (Legal Business Name): JONATHAN W SURDAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 S ROGERS ST
BLOOMINGTON IN
47403-4752
US

IV. Provider business mailing address

583 S CLARIZZ BLVD
BLOOMINGTON IN
47401-5515
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-2663
  • Fax: 812-676-4131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01058877
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: