Provider Demographics
NPI:1477757235
Name:SURJIT S THIARA MD LTD
Entity Type:Organization
Organization Name:SURJIT S THIARA MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:THIARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-562-4014
Mailing Address - Street 1:915 N CARON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-9649
Mailing Address - Country:US
Mailing Address - Phone:815-562-4014
Mailing Address - Fax:815-562-5120
Practice Address - Street 1:915 N CARON RD
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-9649
Practice Address - Country:US
Practice Address - Phone:815-562-4014
Practice Address - Fax:815-562-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45108Medicare UPIN
764860Medicare ID - Type Unspecified
764860Medicare PIN