Provider Demographics
NPI:1679524847
Name:MARUR, SURENDRA (MD)
Entity type:Individual
Prefix:
First Name:SURENDRA
Middle Name:
Last Name:MARUR
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 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 N CHARLES ST STE 203
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-5805
Practice Address - Country:US
Practice Address - Phone:443-849-3760
Practice Address - Fax:443-849-3887
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD66610207R00000X
MISM074095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413597100Medicaid
MD126427ZDDBMedicare PIN
MD725L/126427YRJMedicare PIN
MD413597100Medicaid
MD712L/126427YBPGMedicare PIN
MD126427YVZMedicare PIN
MIH73110Medicare UPIN
MI0P12690Medicare ID - Type Unspecified
MD413597100Medicaid