Provider Demographics
NPI:1902847437
Name:PARUCHURI, SURENDRA P (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:P
Last Name:PARUCHURI
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 1:707 N LOGAN AVE
Mailing Address - Street 2:DANVILLE POLYCLINIC, LTD.
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4730
Mailing Address - Fax:217-477-4749
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:DANVILLE POLYCLINIC, LTD.
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4730
Practice Address - Fax:217-477-4749
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061132207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100014800AMedicaid
IL036061132Medicaid
22387OtherUNITED HEALTHCARE
170580OtherPERSONAL CARE/COVENTRY
110021998Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IL676512Medicare ID - Type UnspecifiedILLINOIS MEDICARE
IN100014800AMedicaid