Provider Demographics
NPI:1063450690
Name:SOURYAL, JEFFREY H (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:H
Last Name:SOURYAL
Suffix:
Gender:M
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 42934
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-2934
Mailing Address - Country:US
Mailing Address - Phone:443-849-2225
Mailing Address - Fax:443-849-3094
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:443-849-2225
Practice Address - Fax:443-849-3094
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD56748207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK647A049Medicare PIN
MDH32440Medicare UPIN