1861592230 NPI number — DR. SUSAN M BRADLEY-BOEHME DMD

Table of content: DR. SUSAN M BRADLEY-BOEHME DMD (NPI 1861592230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861592230 NPI number — DR. SUSAN M BRADLEY-BOEHME DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY-BOEHME
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
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:
1861592230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 CEDARBROOK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCMURRAY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-942-4551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARNEGIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15106-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-279-7366
Provider Business Practice Location Address Fax Number:
412-279-7366
Provider Enumeration Date:
09/25/2006

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: 122300000X , with the licence number:  DS024633L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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