Basic Information
Provider Information | |||||||||
NPI: | 1295711711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUSMAN | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | LOUIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2830 VICTORY PKWY STE 120 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452061786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132453052 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 305 CRESCENT AVENUE | ||||||||
Address2: | UNIVERSITY WYOMING FAMILY PRACTICE CENTER | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 45215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138210275 | ||||||||
FaxNumber: | 5138213621 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2005 | ||||||||
LastUpdateDate: | 09/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.077346 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2163135 | 05 | OH |   | MEDICAID |