1770575755 NPI number — SUSAN NEWTON MD

Table of content: SUSAN NEWTON MD (NPI 1770575755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770575755 NPI number — SUSAN NEWTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEWTON
Provider First Name:
SUSAN
Provider Middle Name:
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:
1770575755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2842 RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-893-5485
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 BAY PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43616-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-690-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2005

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: 207P00000X , with the licence number:  35055954 , 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: 000000246967 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0760636 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000550251 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000271446 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4486186 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4429958 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 810547599026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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