1356362776 NPI number — SUSAN R WIERSMA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356362776 NPI number — SUSAN R WIERSMA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIERSMA
Provider First Name:
SUSAN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1356362776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3605 WARRENSVILLE CENTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAKER HTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-286-6299
Provider Business Mailing Address Fax Number:
216-286-6341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-844-7700
Provider Business Practice Location Address Fax Number:
216-286-6341
Provider Enumeration Date:
07/21/2006

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: 2080P0207X , with the licence number:  35-051050 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 742534 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 200206560A . This is a "OK MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 2056126 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 364131 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000221140 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000027183 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000526169 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2056126 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2093513 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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