1891754321 NPI number — SURAJ BOWRY M.D.

Table of content: SURAJ BOWRY M.D. (NPI 1891754321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891754321 NPI number — SURAJ BOWRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWRY
Provider First Name:
SURAJ
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1891754321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 MILK ST
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT - 9TH FLOOR
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02109-4806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-421-2508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 BROOKLINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215-3904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-421-1999
Provider Business Practice Location Address Fax Number:
617-421-6084
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  34157 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2026139 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: R122 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1671818-001 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 739780 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000848 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B21211601 . This is a "HEALTHSOURCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: C05072 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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