Healthcare Provider Details

I. General information

NPI: 1790811255
Provider Name (Legal Business Name): SUJA T THRASYBULE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 EDISON HWY
BALTIMORE MD
21213
US

IV. Provider business mailing address

9601 PULASKI PARK DR STE 416
BALTIMORE MD
21220-1409
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-4500
  • Fax: 410-675-4556
Mailing address:
  • Phone: 410-933-5678
  • Fax: 410-238-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0051425
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: