Healthcare Provider Details

I. General information

NPI: 1013917855
Provider Name (Legal Business Name): JOHAN SUYDERHOUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-716-3202
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number18449
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2015019918
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2021-02174
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: