Provider Demographics
NPI:1821166554
Name:SURATH, HEMANTHA M (MD)
Entity Type:Individual
Prefix:DR
First Name:HEMANTHA
Middle Name:M
Last Name:SURATH
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 1:2800 N SHERIDAN RD STE 309
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6160
Mailing Address - Country:US
Mailing Address - Phone:773-348-4010
Mailing Address - Fax:773-525-4022
Practice Address - Street 1:2800 N SHERIDAN RD STE 309
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6160
Practice Address - Country:US
Practice Address - Phone:773-348-4010
Practice Address - Fax:773-525-4022
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056232Medicaid
AS7952131OtherDEA
D14737Medicare UPIN
621230Medicare ID - Type Unspecified