Basic Information
| Provider Information | |||||||||
| NPI: | 1134236680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MONARCH PL | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011441099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137342000 | ||||||||
| FaxNumber: | 4137348000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MONARCH PL | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011441099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137342000 | ||||||||
| FaxNumber: | 4137348000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 10/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47484 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-111312 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 234300 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 234300 | 01 | MA | MASS BORM LICENSE | OTHER | 17750357 | 05 | MA | MEDICAID |