1770523870 NPI number — SUSANNA G. EVANS MD

Table of content: MARY FERREE (NPI 1033766555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770523870 NPI number — SUSANNA G. EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
SUSANNA
Provider Middle Name:
G.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1770523870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 CHERRY ST
Provider Second Line Business Mailing Address:
SUITE 11511
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19102-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-255-7822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 SHURS LN
Provider Second Line Business Practice Location Address:
SUITE 409
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19127-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-482-1234
Provider Business Practice Location Address Fax Number:
215-482-0465
Provider Enumeration Date:
06/07/2006

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:  MD417655 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8649657 . This is a "CIGNA HMO/PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2105709000 . This is a "IBC - PC/KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1163241 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 17713-MD417655 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2105709000 . This is a "AMERIHEALTH/INTERCOUNTY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 10926381 . This is a "CAQH ID#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 080191559 . This is a "RRM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1419348 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4641104 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0189959402 . This is a "AMERICHOICE (UHC MA PLAN)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0018995940001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2999717 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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