Basic Information
| Provider Information | |||||||||
| NPI: | 1841288719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOELLIKER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4019219212 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4019219212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 04/05/2019 | ||||||||
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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 | 2085R0202X | 154179 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD08865 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 003111482 | 01 | CT MED ASSISTANCE | OTHER | 007004713 | 01 | HOSPITAL PIN | OTHER | 005220 | 01 | BLUECHIP | OTHER | 3199894 | 01 | HEALTHYSTART | OTHER | 403111 | 01 | TUFTS | OTHER | 000000001988 | 01 | NHPRI | OTHER | 1600203 | 01 | UNITEDHEALTHPLANS | OTHER | 240171 | 01 | RJHPILGRIM | OTHER | 008865 | 01 | BLUESHIELD | OTHER | 300067448 | 01 | RAILROAD MEDICARE | OTHER | 3199894 | 01 | MASSMEDICAID | OTHER | 720053201 | 01 | CIGNA | OTHER | 007004715 | 01 | MEDICARE | OTHER | 7004715 | 01 | RIMEDICALASSISTANCE | OTHER |