Provider Demographics
NPI:1588860761
Name:SUTTIWARA VIPRAKASIT, MD PC
Entity Type:Organization
Organization Name:SUTTIWARA VIPRAKASIT, MD PC
Other - Org Name:SUTTIWARA VIPRAKASIT, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNCEFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-476-1135
Mailing Address - Street 1:1995 HIGHWAY 51 S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-3635
Mailing Address - Country:US
Mailing Address - Phone:901-476-1135
Mailing Address - Fax:901-476-1136
Practice Address - Street 1:1995 HIGHWAY 51 S
Practice Address - Street 2:SUITE 104
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3635
Practice Address - Country:US
Practice Address - Phone:901-476-1135
Practice Address - Fax:901-476-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384839Medicare ID - Type Unspecified