1356743876 NPI number — SOURIAL MORRIS SOURIAL MD

Table of content: (NPI 1356743876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356743876 NPI number — SOURIAL MORRIS SOURIAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOURIAL MORRIS SOURIAL MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOURIAL FP AND PAIN CARE, P.A.
Provider Other Organization Name Type Code:
3
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 Information

NPI Number:
1356743876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16670 S US HIGHWAY 441
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
SUMMERFIELD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34491-8683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-347-1608
Provider Business Mailing Address Fax Number:
888-241-3383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16670 S US HIGHWAY 441
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SUMMERFIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34491-8683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-347-1608
Provider Business Practice Location Address Fax Number:
888-241-3383
Provider Enumeration Date:
09/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SOURIAL
Authorized Official First Name:
SOURIAL
Authorized Official Middle Name:
MORRIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-347-1608

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  OS11425 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000229116 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 151441 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14H1P . This is a "BLUE CROSS AND BLUE SHIELD FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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