Provider Demographics
NPI:1376587683
Name:SURAPANENI, KIRANMAYI (MD)
Entity Type:Individual
Prefix:
First Name:KIRANMAYI
Middle Name:
Last Name:SURAPANENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2433
Mailing Address - Country:US
Mailing Address - Phone:248-541-7606
Mailing Address - Fax:248-541-7197
Practice Address - Street 1:116 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-2433
Practice Address - Country:US
Practice Address - Phone:248-541-7606
Practice Address - Fax:248-541-7197
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4654002Medicaid
MIN69170100Medicare ID - Type Unspecified
MI4654002Medicaid