Provider Demographics
NPI:1356743876
Name:SOURIAL MORRIS SOURIAL MD
Entity type:Organization
Organization Name:SOURIAL MORRIS SOURIAL MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOURIAL
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:SOURIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-347-1608
Mailing Address - Street 1:16670 S US HIGHWAY 441
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8683
Mailing Address - Country:US
Mailing Address - Phone:352-347-1608
Mailing Address - Fax:888-241-3383
Practice Address - Street 1:16670 S US HIGHWAY 441
Practice Address - Street 2:SUITE 103
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8683
Practice Address - Country:US
Practice Address - Phone:352-347-1608
Practice Address - Fax:888-241-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11425261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000229116Medicaid
FL151441OtherHUMANA
FL14H1POtherBLUE CROSS AND BLUE SHIELD FLORIDA
FL14H1POtherBLUE CROSS AND BLUE SHIELD FLORIDA