Provider Demographics
NPI:1750565263
Name:SURYA K. VANGORE M.D. P.C
Entity type:Organization
Organization Name:SURYA K. VANGORE M.D. P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY CARE PHYSCIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SURYA
Authorized Official - Middle Name:KUMARI
Authorized Official - Last Name:VANGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-455-3444
Mailing Address - Street 1:431 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-4148
Mailing Address - Country:US
Mailing Address - Phone:215-455-3444
Mailing Address - Fax:215-455-3445
Practice Address - Street 1:431 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4148
Practice Address - Country:US
Practice Address - Phone:215-455-3444
Practice Address - Fax:215-455-3445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURYA K. VANGORE M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-19
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038910L302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA069175Medicare PIN