Provider Demographics
NPI:1982679551
Name:SURULINARAYANASAMI, LEELA (MD PC)
Entity Type:Individual
Prefix:
First Name:LEELA
Middle Name:
Last Name:SURULINARAYANASAMI
Suffix:
Gender:F
Credentials:MD PC
Other - Prefix:
Other - First Name:LEELA
Other - Middle Name:
Other - Last Name:SURULI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PC
Mailing Address - Street 1:1292 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4811 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2675
Practice Address - Country:US
Practice Address - Phone:734-721-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032052207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382329404OtherTAX ID
MI382329404OtherTAX ID