Healthcare Provider Details

I. General information

NPI: 1093274094
Provider Name (Legal Business Name): PATRICK BOU-SAMRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST # TOWER110
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

225 N CALVERT ST
BALTIMORE MD
21202-4937
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-2050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0213
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: