Basic Information
| Provider Information | |||||||||
| NPI: | 1770242406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDDERTH | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | JAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HAD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUITRAGO | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | JAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 539 B WILSON RD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305293825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068703970 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2406 LIGHTHOUSE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305017401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705364352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | HADS001065 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 237700000X | HADS001065 | GA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | HADS001065 | 01 | GA | GA STATE LICENSE | OTHER |