Basic Information
Provider Information | |||||||||
NPI: | 1851300594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKER | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CONGILOSI | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 575 E RIVER RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857045822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208744135 | ||||||||
FaxNumber: | 5208744135 | ||||||||
Practice Location | |||||||||
Address1: | 1501 N CAMPBELL AVE | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857240001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208744135 | ||||||||
FaxNumber: | 5208744135 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 03/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 36508 | MN | Y |   | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 226217700 | 05 | MN |   | MEDICAID |