1346268141 NPI number — DR. SUSAN F MADERIC M.D.

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 1346268141 NPI number — DR. SUSAN F MADERIC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADERIC
Provider First Name:
SUSAN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1346268141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3395
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47732-3395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10235 HIGHWAY 421 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-268-5500
Provider Business Practice Location Address Fax Number:
502-268-3600
Provider Enumeration Date:
07/18/2006

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:  01068627A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 39244 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50014782 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: M400071155 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201067830 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7795717 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64108541 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 675248 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: K019983 . This is a "MEDICARE EFFECTIVE 10/55/200" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2842542000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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