1053415760 NPI number — MISS SUSAN MICHELE PELL ATC, PA-C

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 1053415760 NPI number — MISS SUSAN MICHELE PELL ATC, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELL
Provider First Name:
SUSAN
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
ATC, PA-C
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:
1053415760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 HOSPITAL WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42503-2872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-451-2628
Provider Business Mailing Address Fax Number:
606-451-2630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-2872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-451-2628
Provider Business Practice Location Address Fax Number:
606-451-2630
Provider Enumeration Date:
09/12/2006

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: 2255A2300X , with the licence number:  001161 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: TC032 , 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)





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