=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932560281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUHRADAM MEDICAL PRACTICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2016
-----------------------------------------------------
Last Update Date | 03/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 TOLL GATE RD
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-438-6004
-----------------------------------------------------
Fax | 860-740-7103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 TOLL GATE RD
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-438-6004
-----------------------------------------------------
Fax | 860-740-7103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRIMAL BABUBHAI PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-438-6004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 049253
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------