Provider Demographics
NPI:1649896127
Name:SURAMED HEALTH CENTER, PA
Entity type:Organization
Organization Name:SURAMED HEALTH CENTER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICS
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-204-2909
Mailing Address - Street 1:683 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1998
Mailing Address - Country:US
Mailing Address - Phone:561-275-7100
Mailing Address - Fax:561-275-7199
Practice Address - Street 1:683 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1998
Practice Address - Country:US
Practice Address - Phone:772-204-2909
Practice Address - Fax:772-785-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009406903Medicaid