1194728139 NPI number — MRS. SUSAN S STEWART P.A.-C

Table of content: MRS. SUSAN S STEWART P.A.-C (NPI 1194728139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194728139 NPI number — MRS. SUSAN S STEWART P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
SUSAN
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SWEENEY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194728139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MAUI MEDICAL GROUP
Provider Second Line Business Mailing Address:
2180 MAIN STREET
Provider Business Mailing Address City Name:
WAILUKU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-242-6464
Provider Business Mailing Address Fax Number:
808-244-0603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MAUI MEDICAL GROUP
Provider Second Line Business Practice Location Address:
2180 MAIN STREET
Provider Business Practice Location Address City Name:
WAILUKU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-242-6464
Provider Business Practice Location Address Fax Number:
808-244-0603
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  003587 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: AMD-974 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00211373D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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