Healthcare Provider Details

I. General information

NPI: 1992915342
Provider Name (Legal Business Name): ACHUTHAN SOURIANARAYANANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DIVISION OF GASTROENTEROLOGY
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DIVISION OF GASTROENTEROLOGY
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-6830
  • Fax: 414-955-6214
Mailing address:
  • Phone: 414-955-6830
  • Fax: 414-955-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35088998
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number46701
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number65061
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number65061
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: