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General NPI Number Information
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NPI Number | 1952583783
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Entity Type | Organization
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Legal Business Name | V SUSARLA MDSC
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 12/21/2007
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Provider Practice Location Address
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Address Line | 860 SUMMIT ST SUITE 123
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City | ELGIN
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State | IL
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Zip | 60120-5145
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Country | US
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Telephone | 847-741-0026
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Fax |
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Provider Business Mailing Address
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Address Line | 860 SUMMIT ST SUITE 123
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City | ELGIN
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State | IL
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Zip | 60120-5145
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Country | US
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Telephone | 847-741-0026
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | VISWANATHAM SUSARLA
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Credential | MD
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Telephone | 847-741-0026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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