Healthcare Provider Details

I. General information

NPI: 1780912790
Provider Name (Legal Business Name): ANGELOS SOURPIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH ST
CHESTNUT HILL MA
02467-3658
US

IV. Provider business mailing address

300 SOUTH ST
CHESTNUT HILL MA
02467-3658
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-0300
  • Fax:
Mailing address:
  • Phone: 617-469-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number242877
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: