Organization
SURYA MEDICAL GROUP SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GANESH N PULLA MD (DOCTOR)
(262) 564-8636
Entity
Organization
Contact information
Practice address
6125 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2928
(262) 564-8636
Mailing address
6125 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2928
(262) 564-8636
Taxonomy
Speciality
Code
Description
License number
State
207QG0300X
Geriatric Medicine (Family Medicine) Physician
Primary
—
—
207RN0300X
Nephrology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
21279800
—
WI
Enumeration date
06/15/2007
Last updated
10/05/2007
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