Provider Demographics
NPI:1326129453
Name:MUKHERJI, SURESH K (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:K
Last Name:MUKHERJI
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 1:804 SERVICE RD
Mailing Address - Street 2:ROOM A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:804 SERVICE RD
Practice Address - Street 2:D100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-5053
Practice Address - Fax:517-432-4394
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010773902085N0700X, 2085R0202X
GUM-21892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326129453Medicaid
MI4284028Medicaid
MI4284028Medicaid
MIF53909Medicare UPIN
MI0C36350095Medicare PIN