MEDICARE: SUPRIYO U GHOSH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	MD0423865	PA

General Provider Information

NPI Number	:	1366430019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUPRIYO U GHOSH MD

Provider Business Mailing Address
First Line	:	888 POPLAR CHURCH RD
Second Line	:
City	:	CAMP HILL
State	:	PA
Zip	:	17011-2205
Country	:	US
Telephone Number	:	717-724-2126
Fax Number	:	717-724-2132

Provider Business Practice Location Address
First Line	:	888 POPLAR CHURCH RD
Second Line	:
City	:	CAMP HILL
State	:	PA
Zip	:	17011-2205
Country	:	US
Telephone Number	:	717-724-2126
Fax Number	:	717-724-2132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	10/16/2007

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