Provider Demographics
NPI:1891754321
Name:BOWRY, SURAJ (MD)
Entity Type:Individual
Prefix:
First Name:SURAJ
Middle Name:
Last Name:BOWRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1999
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA341572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2026139Medicaid
MAR122OtherHARVARD PILGRIM
MA1671818-001OtherCIGNA
MA739780OtherTUFTS
MA0000848OtherNEIGHBORHOOD HEALTH PLAN
MAB21211601OtherHEALTHSOURCE
MAC05072OtherBLUE CROSS
MAC05072OtherBLUE CROSS
MA739780OtherTUFTS