Provider Demographics
NPI:1205831716
Name:CORRIELUS, SANUL (MD)
Entity Type:Individual
Prefix:DR
First Name:SANUL
Middle Name:
Last Name:CORRIELUS
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 1:628 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1617
Mailing Address - Country:US
Mailing Address - Phone:215-383-5900
Mailing Address - Fax:
Practice Address - Street 1:7452 OGONTZ AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1324
Practice Address - Country:US
Practice Address - Phone:215-383-5900
Practice Address - Fax:855-777-8654
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073627L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA049073Medicare ID - Type Unspecified