Healthcare Provider Details

I. General information

NPI: 1508205311
Provider Name (Legal Business Name): SOMU SUPPIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD DEPT OF
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

7401 METRO BLVD STE 210
EDINA MN
55439-3086
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-6032
  • Fax:
Mailing address:
  • Phone: 952-920-4915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number5104-850
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number63501
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: