Basic Information
| Provider Information | |||||||||
| NPI: | 1720060668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANUSI | ||||||||
| FirstName: | H DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANUSI | ||||||||
| OtherFirstName: | HANI | ||||||||
| OtherMiddleName: | DAVID | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 DALLAS HWY | ||||||||
| Address2: | PMB 160 STE 202 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300647505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709206413 | ||||||||
| FaxNumber: | 6789743113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 DALLAS HWY | ||||||||
| Address2: | PMB 160 STE 202 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300647505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709206413 | ||||||||
| FaxNumber: | 6789743113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036450 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036450 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000573185D | 05 | GA | MEDICAID | 000573185F | 05 | GA | MEDICAID | 491431789A | 05 | GA | MEDICAID |