Provider Demographics
NPI:1528227378
Name:SOURWINE, MARIAILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAILEEN
Middle Name:
Last Name:SOURWINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 PENINSULA FARM RD STE I
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1018
Mailing Address - Country:US
Mailing Address - Phone:410-989-8833
Mailing Address - Fax:410-975-5641
Practice Address - Street 1:277 PENINSULA FARM RD STE I
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-1018
Practice Address - Country:US
Practice Address - Phone:410-989-8833
Practice Address - Fax:410-975-5641
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD72591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD72591OtherMARYLAND STATE LICENSE