1811956311 NPI number — SURESH K MENON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811956311 NPI number — SURESH K MENON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MENON

Provider First Name:

SURESH

Provider Middle Name:

K

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1811956311

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/22/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

148 LINDEN DR

Provider Second Line Business Mailing Address:

SUITE 101

Provider Business Mailing Address City Name:

WINCHESTER

Provider Business Mailing Address State Name:

VA

Provider Business Mailing Address Postal Code:

22601-6909

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

540-504-0066

Provider Business Mailing Address Fax Number:

540-678-9025

Provider First Line Business Practice Location Address:

1000 TAVERN RD

Provider Second Line Business Practice Location Address:

SUITE 400

Provider Business Practice Location Address City Name:

MARTINSBURG

Provider Business Practice Location Address State Name:

WV

Provider Business Practice Location Address Postal Code:

25401-2845

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

304-350-8733

Provider Business Practice Location Address Fax Number:

304-350-8655

Provider Enumeration Date:

03/22/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

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• Taxonomy code: 207N00000X , with the licence number:  D55793 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X , with the licence number: D55793 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X , with the licence number: 23521 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: D0055793 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207N00000X , with the licence number: 23521 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: P01520669 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 1811956311 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 404724900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: P00110702 . This is a "RAILROAD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 61692304 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".