1417985623 NPI number — SUSAN KATHLEEN HIRTZ M.D.

Table of content: SUSAN KATHLEEN HIRTZ M.D. (NPI 1417985623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417985623 NPI number — SUSAN KATHLEEN HIRTZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIRTZ
Provider First Name:
SUSAN
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
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:
HIRTZ
Provider Other First Name:
S. KATHLEEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417985623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5720 CRESTVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-5925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-633-3060
Provider Business Mailing Address Fax Number:
352-633-3090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5720 CRESTVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-633-3060
Provider Business Practice Location Address Fax Number:
352-633-3090
Provider Enumeration Date:
06/28/2006

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: 207QA0505X , with the licence number:  MD14264 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME0103996 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1755 . This is a "SAIF" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 117226 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: A156501 . This is a "PACIFICSOURCE PROVIDER ID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 033467000 . This is a "BLUE CROSS PROVIDER ID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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