Basic Information
| Provider Information | |||||||||
| NPI: | 1407834161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUSS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUSS | ||||||||
| OtherFirstName: | S. | ||||||||
| OtherMiddleName: | JOHN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647070 | ||||||||
| FaxNumber: | 7068656268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1478 DOGWOOD DRIVE, SE, SUITES B & C | ||||||||
| Address2: | KAISER PERMANENTE CONYERS MEDICAL CENTER | ||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784134320 | ||||||||
| FaxNumber: | 7068656268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-033938-E | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 054679 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CN0368 | 01 | GA | RR MEDICARE GROUP | OTHER | HOSP60 | 01 | GA | MEDICARE GROUP | OTHER | 015953 | 01 | GA | BCBS | OTHER | 195109401A | 05 | GA | MEDICAID | P00146364 | 01 | GA | RR MEDICARE | OTHER | 197753376 | 05 | GA | MEDICAID | 10063293 | 01 | GA | AMERIGROUP | OTHER | 336284 | 01 | GA | WELLCARE | OTHER |