Healthcare Provider Details

I. General information

NPI: 1780099911
Provider Name (Legal Business Name): ANUSHA SURENDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 DOUSMAN ST
GREEN BAY WI
54303-3211
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301105985
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301105985
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number66784-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: