Basic Information
| Provider Information | |||||||||
| NPI: | 1588603179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUSINI | ||||||||
| FirstName: | LAURENCE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | #100 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204586088 | ||||||||
| FaxNumber: | 5204583983 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | #100 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204586088 | ||||||||
| FaxNumber: | 5204583983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 17611 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 284985 | 05 | AZ | MEDICAID | AZ0779560 | 01 | BCBS AZ | OTHER | 2Z2281 | 01 | HEALTH NET | OTHER |