Provider Demographics
NPI:1043415631
Name:SURYA MEDICAL GROUP SC
Entity Type:Organization
Organization Name:SURYA MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GANESH
Authorized Official - Middle Name:N
Authorized Official - Last Name:PULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-564-8636
Mailing Address - Street 1:6125 GREEN BAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2928
Mailing Address - Country:US
Mailing Address - Phone:262-564-8636
Mailing Address - Fax:
Practice Address - Street 1:6125 GREEN BAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2928
Practice Address - Country:US
Practice Address - Phone:262-564-8636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21279800Medicaid