Basic Information
| Provider Information | |||||||||
| NPI: | 1821075995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEFFY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADAMS | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | STE.3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 CAREW ST | ||||||||
| Address2: | STE. 260 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739380 | ||||||||
| FaxNumber: | 2603739399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01041631A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00001426252 07 | 01 | UNITED HEALTHCARE | OTHER | 200027920 | 05 | IN | MEDICAID | 4676263 | 01 | AETNA | OTHER | 000000264512 | 01 | IL | ANTHEM | OTHER | 10623 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 3937240010 | 01 | IN | MEDICARE DMEPOS | OTHER |