1730179284 NPI number — DR. SUSAN A DEMUTH M.D.

Table of content: DR. SUSAN A DEMUTH M.D. (NPI 1730179284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730179284 NPI number — DR. SUSAN A DEMUTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMUTH
Provider First Name:
SUSAN
Provider Middle Name:
A
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:
SHULTIS
Provider Other First Name:
SUSAN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730179284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
KIMBROUGH AMBULATORY CARE CENTER
Provider Second Line Business Mailing Address:
ATTN: MCXR-CR 2480 LLEWELLYN AVE.
Provider Business Mailing Address City Name:
FT. MEADE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-677-8270
Provider Business Mailing Address Fax Number:
301-677-8176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2480 LLEWELLYN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT MEADE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20755-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-677-8641
Provider Business Practice Location Address Fax Number:
301-677-8485
Provider Enumeration Date:
10/26/2005

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: 208000000X , with the licence number:  0101037909 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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