Basic Information
| Provider Information | |||||||||
| NPI: | 1417045964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUSCO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4706 CAMERON RIDGE DR | ||||||||
| Address2: | APT 134 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462407668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654125469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5949 W RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462414348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172471579 | ||||||||
| FaxNumber: | 3172471612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009067A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 36001336A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.