Basic Information
Provider Information | |||||||||
NPI: | 1457359598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NASRI | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2914 S REPUBLIC BLVD | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436151912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4195318808 | ||||||||
FaxNumber: | 4195319342 | ||||||||
Practice Location | |||||||||
Address1: | 5734 COVENTRY LN | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468047141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604367875 | ||||||||
FaxNumber: | 2604329812 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 11/20/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01052481 | IN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 050087310 | 01 | IN | RAILROAD MEDICARE | OTHER | 200357570 | 05 | IN |   | MEDICAID | 163856 | 01 | IN | CSHCS | OTHER | 163855 | 01 | IN | CSHCS | OTHER | 163857 | 01 | IN | CSHCS | OTHER |