Basic Information
| Provider Information | |||||||||
| NPI: | 1760440374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURESH | ||||||||
| FirstName: | KEELAPANDAL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21245 LORAIN RD | ||||||||
| Address2: | STE 206 | ||||||||
| City: | FAIRVIEW PARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441262140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 21851 CENTER RIDGE RD | ||||||||
| Address2: | 309 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441163976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403338322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 35059258 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 000000543804 | 01 | ANTHEM | OTHER | 9273172 | 01 | MEDICARE PHYSICIAN GROUP | OTHER | 0880917 | 05 | OH | MEDICAID |