Healthcare Provider Details

I. General information

NPI: 1003050113
Provider Name (Legal Business Name): MR. SURESH KUMAR KOMIRISETTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W MOUNT HOPE AVE
LANSING MI
48910-2660
US

IV. Provider business mailing address

1795 NEMOKE CT APARTMENT # 9
HASLETT MI
48840-8679
US

V. Phone/Fax

Practice location:
  • Phone: 517-372-6700
  • Fax: 517-372-0616
Mailing address:
  • Phone: 270-535-8708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302034766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: