Provider Demographics
NPI:1043261522
Name:MAHBOUBI, SOROOSH (MD)
Entity type:Individual
Prefix:DR
First Name:SOROOSH
Middle Name:
Last Name:MAHBOUBI
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9232
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA - RADIOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-7000
Practice Address - Fax:215-590-9348
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD035194L2085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006461470001Medicaid
PA0006461470001Medicaid
PA0006461470001Medicaid
B33709Medicare UPIN