Basic Information
| Provider Information | |||||||||
| NPI: | 1770523870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 SHURS LN | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191272123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154821234 | ||||||||
| FaxNumber: | 2154820465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD417655 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8649657 | 01 | PA | CIGNA HMO/PPO | OTHER | 2105709000 | 01 | PA | IBC - PC/KHPE | OTHER | 1163241 | 01 | PA | KEYSTONE MERCY | OTHER | 17713-MD417655 | 01 | PA | HEALTH PARTNERS | OTHER | 2105709000 | 01 | PA | AMERIHEALTH/INTERCOUNTY | OTHER | 10926381 | 01 | PA | CAQH ID# | OTHER | 080191559 | 01 | PA | RRM | OTHER | 1419348 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 4641104 | 01 | PA | AETNA PPO | OTHER | 0189959402 | 01 | PA | AMERICHOICE (UHC MA PLAN) | OTHER | 0018995940001 | 05 | PA | MEDICAID | 2999717 | 01 | PA | AETNA HMO | OTHER |