1174746150 NPI number — MRS. SUSAN MOTTESHEARD TATUM RD

Table of content: MRS. SUSAN MOTTESHEARD TATUM RD (NPI 1174746150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174746150 NPI number — MRS. SUSAN MOTTESHEARD TATUM RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATUM
Provider First Name:
SUSAN
Provider Middle Name:
MOTTESHEARD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOTTESHEARD
Provider Other First Name:
SUSAN
Provider Other Middle Name:
DALE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174746150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 758997
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-828-2841
Provider Business Mailing Address Fax Number:
804-628-0783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 E. MARSHAL STREET
Provider Second Line Business Practice Location Address:
CLINICAL NUTRITION
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23298-0294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-828-0970
Provider Business Practice Location Address Fax Number:
804-628-0921
Provider Enumeration Date:
04/10/2007

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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