Provider Demographics
NPI:1174226609
Name:GOURNENI, SURYA (MD)
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:GOURNENI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1507
Mailing Address - Country:US
Mailing Address - Phone:703-597-2629
Mailing Address - Fax:
Practice Address - Street 1:60 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2220
Practice Address - Country:US
Practice Address - Phone:215-663-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program