1285684035 NPI number — MRS. SUSAN DAVIS CRNP

Table of content: MRS. SUSAN DAVIS CRNP (NPI 1285684035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285684035 NPI number — MRS. SUSAN DAVIS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285684035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 W BELVEDERE AVE
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21215-5216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-601-5524
Provider Business Mailing Address Fax Number:
410-601-8946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2435 W BELVEDERE AVE
Provider Second Line Business Practice Location Address:
SUITE 35
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215-5224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-601-0900
Provider Business Practice Location Address Fax Number:
410-601-0901
Provider Enumeration Date:
05/11/2006

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: 363LA2100X , with the licence number:  R093098 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00125781 . This is a "R/R MEDICARE PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: CC1918 . This is a "R/R MEDICARE GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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