MEDICARE: MS. MOUSOOMI M. SUR 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	207Q00000X	Family Medicine Physician	M-9645	ID

General Provider Information

NPI Number	:	1518968841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MOUSOOMI M. SUR MD

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:	208-381-2222
Fax Number	:

Provider Business Practice Location Address
First Line	:	2083 E HOSPITALITY LN
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83716-6603
Country	:	US
Telephone Number	:	208-333-8345
Fax Number	:

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	09/15/2012

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