Healthcare Provider Details

I. General information

NPI: 1710987581
Provider Name (Legal Business Name): BRIAN SCOTT SUCHARETZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PARK PLACE SUITE 200
MISHAWAKA IN
46545-3566
US

IV. Provider business mailing address

515 PARK PLACE SUITE 200
MISHAWAKA IN
46545-3566
US

V. Phone/Fax

Practice location:
  • Phone: 574-607-4724
  • Fax: 574-607-4725
Mailing address:
  • Phone: 574-607-4724
  • Fax: 574-607-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01042730A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: