Provider Demographics
NPI:1962424390
Name:GHOSH, SURESH CHANDRA (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:CHANDRA
Last Name:GHOSH
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-807-8000
Mailing Address - Fax:215-831-2017
Practice Address - Street 1:5000 FRANKFORD AVE
Practice Address - Street 2:WAKELING BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2620
Practice Address - Country:US
Practice Address - Phone:215-831-2355
Practice Address - Fax:215-831-2017
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032109L2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008205440005Medicaid
PA0052523000OtherINDEPENDENCE BLUE CROSS
PA037241OtherHIGHMARK BLUE SHIELD
PA5574330OtherAETNA PPO
PA6974266OtherAETNA HMO
PA30685MD032109LOtherHEALTH PARTNERS
PA30065497OtherKEYSTONE MERCY
PA0008205440005Medicaid
PA5574330OtherAETNA PPO