Individual
DR. JONATHAN W SURDAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1302 S ROGERS ST, BLOOMINGTON, IN 47403-4752
(812) 333-2663
(812) 676-4131
Mailing address
583 S CLARIZZ BLVD, BLOOMINGTON, IN 47401-5515
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
01058877
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200479570
—
IN
01
—
P00146258
RAILROAD MEDICARE
IN
Enumeration date
11/07/2005
Last updated
12/23/2020
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