Provider Demographics
NPI:1366430019
Name:GHOSH, SUPRIYO U (MD)
Entity type:Individual
Prefix:
First Name:SUPRIYO
Middle Name:U
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 1:888 POPLAR CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2205
Mailing Address - Country:US
Mailing Address - Phone:717-724-2126
Mailing Address - Fax:717-724-2132
Practice Address - Street 1:888 POPLAR CHURCH RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2205
Practice Address - Country:US
Practice Address - Phone:717-724-2126
Practice Address - Fax:717-724-2132
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0423865207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H16423Medicare UPIN
PA019219Medicare PIN