Provider Demographics
NPI:1417114620
Name:SURAVARAM, SMITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SMITHA
Middle Name:
Last Name:SURAVARAM
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 1:1497 BURBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-2187
Mailing Address - Country:US
Mailing Address - Phone:507-271-6244
Mailing Address - Fax:
Practice Address - Street 1:121 FAIRFIELD WAY
Practice Address - Street 2:STE 207
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1588
Practice Address - Country:US
Practice Address - Phone:630-529-7427
Practice Address - Fax:630-529-9937
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128727207Q00000X
MI4301092015390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine