Provider Demographics
NPI:1932198736
Name:BRADENTON WOMEN'S CENTER PA
Entity Type:Organization
Organization Name:BRADENTON WOMEN'S CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURICHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURATTANONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-708-5045
Mailing Address - Street 1:3950 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-9059
Mailing Address - Country:US
Mailing Address - Phone:941-708-5045
Mailing Address - Fax:
Practice Address - Street 1:3950 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9059
Practice Address - Country:US
Practice Address - Phone:941-708-5045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K1589Medicare ID - Type Unspecified