Provider Demographics
NPI:1003877481
Name:SURAPIPITH, PONGCHAYUT (MD)
Entity Type:Individual
Prefix:
First Name:PONGCHAYUT
Middle Name:
Last Name:SURAPIPITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-4968
Mailing Address - Country:US
Mailing Address - Phone:810-342-5500
Mailing Address - Fax:810-342-5545
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-342-1000
Practice Address - Fax:810-342-1590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044139208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1008625OtherHEALTH ADVANTAGE
MI4525121Medicaid
MI1008625OtherMCLAREN HEALTH PLAN
MIA78286OtherHEALTH NET FEDERAL SERVIC
MI0202510851OtherBLUE CROSS BLUE SHIELD
MI4735595Medicaid
MI4735595Medicaid
MI4525121Medicaid