Healthcare Provider Details

I. General information

NPI: 1407939887
Provider Name (Legal Business Name): JEFFREY GIDEON SUICO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD LILLY CLINIC - IU HOSPITAL AOC
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

4324 SEDGE CT
ZIONSVILLE IN
46077-8520
US

V. Phone/Fax

Practice location:
  • Phone: 317-276-4758
  • Fax:
Mailing address:
  • Phone: 317-769-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01042153
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: