Basic Information
Provider Information | |||||||||
NPI: | 1629099569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAURENCE M SUSINI MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 155 CALLE PORTAL STE 100 | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856352900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204586088 | ||||||||
FaxNumber: | 5204583983 | ||||||||
Practice Location | |||||||||
Address1: | 155 CALLE PORTAL STE 100 | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856352900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204586088 | ||||||||
FaxNumber: | 5204583983 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2006 | ||||||||
LastUpdateDate: | 04/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAPLAN | ||||||||
AuthorizedOfficialFirstName: | SANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTS | ||||||||
AuthorizedOfficialTelephone: | 5204586331 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 17611 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 284985 | 05 | AZ |   | MEDICAID | AZ0779560 | 01 | AZ | BCBSAZ | OTHER |