1184664146 NPI number — PETER SU MD

Table of content: PETER SU MD (NPI 1184664146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184664146 NPI number — PETER SU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SU
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1184664146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1438 DEFENSE HIGHWAY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
GAMBRILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-721-3200
Provider Business Mailing Address Fax Number:
410-721-2680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1438 DEFENSE HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GAMBRILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-721-3200
Provider Business Practice Location Address Fax Number:
410-721-2680
Provider Enumeration Date:
06/07/2006

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: 207Q00000X , with the licence number:  D0056977 , 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: 407044800 . This is a "MEDICAL ASSISTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 558223 . This is a "INFORMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1S80P . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: F1880001 . This is a "BCBS FEDERAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13564 . This is a "JOHNS HOPKINS HLTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7120279 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: F1880001 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: P15312 . This is a "BCBS MPOS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407048800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4301934 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: F1880001 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 165131 . This is a "COVENTRY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 223342 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 223342 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".




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