Provider Demographics
NPI:1598706194
Name:SURA, PATRICK D (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:D
Last Name:SURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN ST E
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1439
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0311
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27820020207Q00000X
WI27820208100000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31389500Medicaid
WI004960156Medicare Oscar/Certification