Provider Demographics
NPI:1447369020
Name:BOU SAMRA, GEORGE R (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:BOU SAMRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 LOWRY AVE
Mailing Address - Street 2:BLDG A
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-3063
Mailing Address - Country:US
Mailing Address - Phone:724-374-5920
Mailing Address - Fax:724-374-5873
Practice Address - Street 1:126 E CHURCH ST STE 3100
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2274
Practice Address - Country:US
Practice Address - Phone:814-445-7101
Practice Address - Fax:814-445-7688
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-067949-L207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA025444OtherMEDICARE
PA001751503Medicaid
PA001751503Medicaid