Provider Demographics
NPI:1982054730
Name:JAIN, SURBHI (MD)
Entity type:Individual
Prefix:
First Name:SURBHI
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 GOLD HILL RD
Practice Address - Street 2:SUITE 115
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:803-802-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83573207R00000X
NC2019-02812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTRN# 22645OtherFLORIDA HEALTH-BOARD OF MEDICINE