Provider Demographics
NPI:1881066504
Name:SURESH PERSAD MD PC
Entity type:Organization
Organization Name:SURESH PERSAD MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWOSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-352-7936
Mailing Address - Street 1:361 COMMERCIAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3659
Mailing Address - Country:US
Mailing Address - Phone:912-352-7936
Mailing Address - Fax:912-352-0079
Practice Address - Street 1:361 COMMERCIAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3659
Practice Address - Country:US
Practice Address - Phone:912-352-7936
Practice Address - Fax:912-352-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17717207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000069231AMedicaid