Provider Demographics
NPI:1760792881
Name:SURYA K NALLARI MD
Entity Type:Organization
Organization Name:SURYA K NALLARI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:NALLARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-987-6010
Mailing Address - Street 1:404 10TH ST SW
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-9298
Mailing Address - Country:US
Mailing Address - Phone:219-987-6010
Mailing Address - Fax:
Practice Address - Street 1:404 10TH ST SW
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9298
Practice Address - Country:US
Practice Address - Phone:219-987-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037891A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201009800AMedicaid
IN201009800BMedicaid
IN000000209586OtherANTHEM
IN201009800CMedicaid
IN000000209586OtherANTHEM