Provider Demographics
NPI:1508895640
Name:SURESH GUPTA MD INC
Entity Type:Organization
Organization Name:SURESH GUPTA MD INC
Other - Org Name:PAIN MANAGEMENT ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SAPNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-620-0720
Mailing Address - Street 1:1010 WOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1400
Mailing Address - Country:US
Mailing Address - Phone:937-424-2215
Mailing Address - Fax:937-252-1224
Practice Address - Street 1:1010 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432
Practice Address - Country:US
Practice Address - Phone:937-424-2215
Practice Address - Fax:937-252-1224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 332B00000X
OH261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2059481Medicaid
7683860001OtherMEDICARE NSC
OH9276732OtherMEDICARE