Provider Demographics
NPI:1093427114
Name:SOROUR, OSAMA (MBCHB)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:
Last Name:SOROUR
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3096
Mailing Address - Country:US
Mailing Address - Phone:617-573-6917
Mailing Address - Fax:
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3096
Practice Address - Country:US
Practice Address - Phone:617-573-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3013577390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
199463OtherEGYPTIAN MEDICAL SYNDICATE