Basic Information
| Provider Information | |||||||||
| NPI: | 1982961751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | REBECCA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCMAHON | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | REBECCA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3515 MASSILLON RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446856400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 COMMUNITY RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442782358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306336601 | ||||||||
| FaxNumber: | 3306334476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 35125325 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0121930 | 05 | OH | MEDICAID |