Individual
MR. SURAJ BOPANNA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD, MRCP
Contact information
Practice address
1401 E STATE ST, ROCKFORD, IL 61104
(779) 696-6102
Mailing address
PO BOX 78866, MILWAUKEE, WI 53278-8866
(779) 696-7150
(779) 696-7342
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
40265
IA
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
036-126456
IL
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
40265
IA
207RP1001X
Pulmonary Disease Physician
Primary
036-126456
IL
207RP1001X
Pulmonary Disease Physician
40265
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100181898
—
WI
Enumeration date
10/28/2008
Last updated
03/04/2024
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