Healthcare Provider Details

I. General information

NPI: 1154350940
Provider Name (Legal Business Name): ARIEF SURIAWINATA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DHMC - PATHOLOGY
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DHMC DEPARTMENT OF PATHOLOGY
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-7048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number11978
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: