Provider Demographics
NPI:1982818332
Name:DR SADTHA SURATTANONT
Entity Type:Organization
Organization Name:DR SADTHA SURATTANONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SADTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURATTANONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-822-4241
Mailing Address - Street 1:PO BOX 1980
Mailing Address - Street 2:55 NORTH BOLTON ST
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-1980
Mailing Address - Country:US
Mailing Address - Phone:303-822-4241
Mailing Address - Fax:304-822-3344
Practice Address - Street 1:55 NORTH BOLTON ST
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-1980
Practice Address - Country:US
Practice Address - Phone:304-822-4241
Practice Address - Fax:304-822-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10426208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720280OtherBCBS
550623785OtherACORDIA PEIA
WV0127798000Medicaid
550623785OtherACORDIA PEIA
WV0127798000Medicaid